Dual Antiplatelet Therapy After Percutaneous Coronary Intervention With Stent Implantation in Patients Taking Chronic Oral Anticoagulation Renata Rogacka, Alaide Chieffo, Iassen Michev, Flavio ...Airoldi, Azeem Latib, John Cosgrave, Matteo Montorfano, Mauro Carlino, Giuseppe M. Sangiorgi, Alfredo Castelli, Cosmo Godino, Valeria Magni, Tiziana C. Aranzulla, Enrico Romagnoli, Antonio Colombo The optimal antithrombotic strategy after percutaneous coronary intervention (PCI) and stent implantation for patients taking long-term anticoagulation is unclear. In this study, 127 consecutive patients who underwent PCI with stent implantation and were discharged on triple therapy were analyzed. While taking triple therapy, 6 patients (4.7%) developed major bleeding, 50% of which were lethal. No significant differences between drug-eluting and bare-metal stents were observed in the incidence of bleeding complications and mortality.
Intraprocedural stent thrombosis (IPST) is a rare event (<0.01% in our experience with bare metal stents), with the exception of specific settings such as acute myocardial infarction, ...thrombus-containing lesions, and dissections. We report the occurrence of this event during elective implantation of sirolimus-eluting stents.
Between April 2002 and August 2003, 670 patients with 1362 lesions were treated with Cypher (Cordis, Johnson and Johnson Co) sirolimus-eluting stent implantation in San Raffaele Hospital and EMO Centro Cuore Columbus. Diabetes mellitus was present in 142 patients (21%), and 164 (24.5%) had unstable angina. Pretreatment with glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors was carried out in 235 patients (35%). Total stent length per vessel was 42.9+/-28.3 mm. IPST occurred in 5 patients (0.7%). None of the patients with IPST were pretreated with GP IIb/IIIa inhibitors. Using univariate exact logistic regression, only total stent length per vessel, in millimeters (exact OR, 1.03; 95% CI, 1.011 to 1.046; P=0.0028), was associated with the occurrence of IPST.
Stent length was associated with the occurrence of IPST. Particular attention will need to be directed to this potential complication when long sirolimus-eluting stents are being used.
The use of intravascular ultrasound (IVUS) to improve acute angiographic results was already shown in the prestent era. Various studies demonstrated the efficacy of IVUS in balloon sizing and ...estimating the extent of positive remodeling. With the introduction of drug-eluting stents (DES) the rate of restenosis has been significantly reduced but a new concern, the risk of stent thrombosis, has emerged. The association of stent underexpansion with stent thrombosis was observed for bare metal stents (BMS) and DES. Until now, the criteria for IVUS optimization used in different studies have relied on distal reference or on mean reference vessel for stent or postdilatation balloon sizing. Furthermore, an important recent innovation not available in previous studies is the use of noncompliant balloons to perform high pressure post-dilatation. Universal and easily applicable IVUS criteria for optimization of stent implantation as well as randomized studies on IVUS-guided DES implantation are necessary to minimize stent malapposition and underexpansion, which in turn can positively influence the rates of stent restenosis and thrombosis.
In patients with in-stent restenosis (ISR) inside bare metal stents, drug-eluting stents reduce the recurrence of restenosis compared with balloon angioplasty. However, few data are available about ...this therapeutic modality in the case of diffuse restenosis. The aim of this study was to evaluate the immediate and mid-term outcome of sirolimus- and paclitaxel-eluting stent implantation in diffuse ISR and determine the predictors of clinical and angiographic restenosis recurrence. A series of 161 consecutive patients with 194 diffuse ISR lesions (>10 mm) treated with drug-eluting stent implantation were evaluated. Major adverse cardiac events were defined as death, myocardial infarction, and the need for target lesion revascularization. During a mean follow-up of 8.2 ± 3.4 months, the cumulative incidence of major adverse cardiac events was 19% in the SES group and 24% in the PES group (p = 0.56). Angiographic follow-up was performed in 80% of the lesions. The overall restenosis rate was 22% and was not significantly different between lesions treated with sirolimus-eluting (20%) or paclitaxel-eluting (25%, p = 0.55) stents. The incidence of restenosis was higher in diabetics (32%) than in nondiabetics (16%, odds ratio 2.5, 95% confidence interval 1.1 to 5.5, p = 0.02). By multivariate analysis, diabetes was confirmed to be the only independent predictor of recurrent restenosis (odds ratio 3.53, 95% confidence interval 1.39 to 9.02, p = 0.008). In conclusion, drug-eluting stent implantation for diffuse ISR is associated with acceptable clinical and angiographic results. The association of diffuse restenosis and diabetes mellitus is an unfavorable condition leading to a high risk of recurrence.
Sixty in-stent restenotic lesions were treated with sirolimus-eluting stent implantation and retrospectively compared with a group of matched lesions treated with cutting balloon angioplasty. The ...results indicate a good safety profile of the procedure and a 57% reduction in the incidence of recurrent restenosis in comparison with cutting balloon angioplasty.
Acute coronary syndromes (ACS) have been classified according to the finding of ST-segment elevation on the presenting electrocardiogram, with different treatment strategies and practice guidelines. ...However, a comparative description of the clinical characteristics and outcomes of acute coronary syndrome elderly patients undergoing percutaneous coronary intervention during index admission has not been published so far.
Retrospective cohort study of patients enrolled in the Elderly ACS-2 multicenter randomized trial. Main outcome measures were crude cumulative incidence and cause-specific hazard ratio (cHR) of cardiovascular death, noncardiovascular death, reinfarction, and stroke.
Of 1443 ACS patients aged >75 years (median age 80 years, interquartile range 77-84), 41% were classified as ST-elevation myocardial infarction (STEMI), and 59% had non-ST-elevation ACS (NSTEACS) (48% NSTEMI and 11% unstable angina). As compared with those with NSTEACS, STEMI patients had more favorable baseline risk factors, fewer prior cardiovascular events, and less severe coronary disease, but lower ejection fraction (45% vs 50%, P < .001). At a median follow-up of 12 months, 51 (8.6%) STEMI patients had died, vs 39 (4.6%) NSTEACS patients. After adjusting for sex, age, and previous myocardial infarction, the hazard among the STEMI group was significantly higher for cardiovascular death (cHR 1.85; 95% confidence interval CI, 1.02-3.36), noncardiovascular death (cHR 2.10; 95% CI, 1.01-4.38), and stroke (cHR 4.8; 95% CI, 1.7-13.7).
Despite more favorable baseline characteristics, elderly STEMI patients have worse survival and a higher risk of stroke compared with NSTEACS patients after percutaneous coronary intervention.
Background drug-coated balloons (DCB) have an acknowledged role for the treatment of in-stent restenosis (ISR), and there is some initial evidence of their efficacy for treatment of de novo lesions, ...especially in small coronary vessels. Conclusion this registry on the performance of a new generation DCB showed good procedural success in both ISR and de novo lesions, and a significantly lower rate of TLR in patients treated for de novo lesions at mid-term clinical follow up.
The presence of a lumen narrowing at the ostium and the body of an unprotected left main coronary artery but does not require bifurcation treatment is a class I indication of surgical ...revascularization.
A total of 147 consecutive patients who had a stenosis in the ostium and/or the midshaft of an unprotected left main coronary artery (treatment of the bifurcation not required) and were electively treated with percutaneous coronary intervention and sirolimus-eluting stents (n=107) or paclitaxel-eluting stents (n=40) in 5 centres were included in this registry. In 72 patients (almost 50%), intravascular ultrasound guidance was performed. Procedural success was achieved in 99% of the patients; in 1 patient with stenosis in the left main coronary artery ostium, a >30% residual stenosis persisted at the end of the procedure, and the patient was referred for coronary artery bypass graft surgery. During hospitalization, no patients experienced a Q-wave myocardial infarction or died. One patient died 19 days after the procedure because of pulmonary infection. At long-term clinical follow-up (886+/-308 days), 5 patients had died; 7 patients had target vessel revascularization (5 repeat percutaneous coronary interventions and 2 coronary artery bypass graft surgeries), and of these only 1 patient had a target lesion revascularization. Angiographic follow-up was performed in 106 patients (72%) with a late loss of -0.01 mm. Restenosis in the left main trunk occurred only in 1 patient (0.9%).
Percutaneous coronary intervention with sirolimus-eluting stents or paclitaxel-eluting stents implantation in nonbifurcation left main coronary artery lesions appears safe with a long-term major adverse clinical event rate of 7.4% and a restenosis rate of 0.9%.
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