Usefulness of Coronary Pressure Measurement for Functional Evaluation of Drug-Eluting Stent Restenosis (original) (raw)
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Aims The evaluation of in-stent restenosis (ISR) is usually based on angiographic quantification. This evaluation is sometimes difficult and it has not an accurate clinical correlation. Fractional flow reserve (FFR) measured by intracoronary pressure wire has demonstrated its value in determining the functional repercussion of coronary stenosis. The aim of this study was to evaluate the relation between quantitative angiography-FFR in borderline in-stent restenotic lesions and the accuracy of FFR in deciding the treatment of ISR.
Distribution of angiographic measures of restenosis after drug-eluting stent implantation
Heart, 2009
Background: A bimodal distribution of measures of restenosis has been demonstrated at 6-8 months after bare metal stent implantation. Drug-eluting stent (DES) treatment has attenuated the impact of certain factors (eg, diabetes) on restenosis but its effect on the distribution of indices of restenosis is not known. Objective: To perform a detailed analysis of the metrics of restenosis indices after DES implantation. Design, settings, patients: Prospective observational study of patients undergoing DES implantation (Cypher, sirolimus-eluting stent; or Taxus, paclitaxel-eluting stent) at two German centres, with repeat angiography scheduled at 6-8 months after coronary stenting. Main outcome measures: In-stent late luminal loss (LLL) and in-segment percentage diameter stenosis (%DS) as determined by quantitative coronary angiography at recatheterisation. Results: Paired cineangiograms were available for 2057 patients. Overall mean (SD) LLL was 0.31 (0.50) mm; mean (SD) %DS was 30.3 (15.7)%. Distribution of both LLL and %DS differed significantly from normal (Kolmogorov-Smirnov test; p,0.001 for each). For both parameters a mixed distribution model better described the data (likelihood ratio test with 3df; p,0.001 for each). This consisted of two normally distributed subpopulations with means (SD) of 0.10 (0.25) mm and 0.69 (0.60) mm for LLL, and means (SD) of 22.2 (8.6)% and 40.1 (16.6)% for %DS. The results were consistent across subgroups of DES type, ''on-label'' versus ''off-label'' indication, and presence or absence of diabetes. Conclusions: LLL and %DS at follow-up angiography after DES implantation have a complex mixed distribution that may be accurately represented by a bimodal distribution model. The introduction of DES treatment has not resulted in elimination of a variable propensity to restenosis among subpopulations of patients with stented lesions.
Global Journal of Health Science, 2015
Measuring fractional flow reserve (FFR) in percutaneous coronary intervention (PCI) has predictive value for PCI outcome. We decided to examine the utility of pre-and post-stenting FFR as a predictor of 6-month stent restenosis as well as MACE (major adverse cardiac events). Pre-and post-stenting FFR values were measured for 60 PCI patients. Within 6 months after stenting, all patients were followed for assessment of cardiac MACE including myocardial infarction, unstable angina, or positive exercise test. Stent restenosis was also assessed. Cutoff values for pre-and post-stenting FFR measurements were considered respectively as 0.65 and 0.92.Stent restenosis was detected in 4 patients (6.6%). All 4 patients (100%) with restenosis had pre-stenting FFR of < 0.65, while only 26 of 56 patients without restenosis (46.4%) had pre-stenting FFR value of < 0.65 (P = 0.039). Mean pre-stenting FFR in patients with restenosis was significantly lower than in those without restenosis (0.25 ± 0.01 vs. 0.53 ± 0.03, P = 0.022). Although stent restenosis was higher in patients with post-stenting FFR of < 0.92 (2 cases, 9.5%) than in those with FFR value of ≥ 0.92 (2 cases, 5.1%), the difference was not statistically (P = 0.510). Pre-stenting FFR, the use of longer stents, and history of diabetes mellitus can predict stent restenosis, but the value of post-stenting FFR for predicting restenosis was not explicit.
Korean Circulation Journal, 2009
The aim of this study was to evaluate the outcomes of repeated percutaneous coronary intervention (PCI) based on the restenosis pattern in drug-eluting stent (DES) failure. Subjects and Methods: From April 2003 to March 2006, all 67 patients (67 lesions) at our 3 centers who had DES in-stent restenosis (ISR) were enrolled. The patients were divided into 3 groups : group I had focal edge restenosis, group II had focal body restenosis, and group III had non-focal restenosis. All patients were treated with conventional PCI including plain old balloon angioplasty (POBA), cutting balloon angioplasty (CBA), and repeated DES implantation (Re-DES). Angiographic and clinical one year follow-up results for the 3 groups were evaluated. Results: Sixteen patients were enrolled in group I, 36 in group II, and 15 in group III. Baseline clinical and angiographic characteristics and the proportion of patients in each group receiving each type of treatment strategy were not significantly different among the groups. Within each group, a comparison of angiographic and clinical outcomes for each therapeutic modality revealed that restenosis rates were not statistically different. Although rates of major adverse cardiac events (MACE) were not statistically different between groups I and II, in group III, MACE were 3-fold higher for the POBA (4/4, 100.0%) and CBA (4/4, 100.0%) subgroups than for Re-DES (1/3, 33.3%) (p=0.06), but the differences did not reach statistical significance. Conclusion: The present study suggests that treatment of DES ISR should be individualized according to restenosis pattern : any PCI strategy appears appropriate for focal ISR patterns, while Re-DES might be a better choice for non-focal ISR patterns. ( Korean Circ J 2009;39:408-413 )
Circulation: Cardiovascular Interventions
O n the basis of robust scientific 1,2 and clinical outcome data derived from large randomized controlled trials and registries, 3-18 fractional flow reserve (FFR) has become the standard for clinical decision making about percutaneous coronary revascularization. FFR has a Class I indication with a level of evidence A in stable patients to identify hemodynamically significant coronary lesions when evidence of ischemia is not available. 19 Recent prospective outcome data, obtained in medically treated patients, indicated a risk continuum for FFR values from 0 to 1, where the lower the FFR the higher the long-term event rate. 18,20 However, it is still unclear whether a similar correlation is maintained after revascularization because the clinical value of FFR to evaluate the results of percutaneous coronary intervention (PCI) has not been prospectively investigated in the drug-eluting stent (DES) era.
Circulation Journal, 2013
Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp versible myocardial ischemia. Therefore, FFR has been proposed as a useful variable to decide on the performance of percutaneous coronary intervention (PCI). 8-10 In not only the bare metal stent (BMS) but also the DES eras, studies are available that have reported a good prognosis in patients who had angiographic restenosis if their FFR is preserved. 11-14 The objective of the present study was to assess the functional severity of stenosis in patients with moderate angiographic restenosis after PES deployment and their counterparts with moderate de novo stenosis. Methods Subjects The present study enrolled 42 Japanese patients who had moderate angiographic restenosis that was estimated as 75% on American Heart Association (AHA) classification (51-75% by irolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) have been widely used as first-generation drugeluting stents (DES), and various controlled trials and meta-analyses have raised some concerns about differences in the incidences of restenosis and target lesion revascularization (TLR). 1-6 Many of these studies have shown that late lumen loss is significantly less with SES than with PES. In contrast, clinical follow-up alone tends to indicate that the incidences of death and myocardial infarction are similar to those determined on coronary angiography (CAG), although the incidence of TLR thus determined is lower. 7 This suggests that the decision to conduct TLR based on CAG alone when assessing restenosis at the chronic stage after PES deployment probably leads to the overtreatment of PES-deployed patients. Fractional flow reserve (FFR) is well known as a useful index for the physiological severity of coronary artery stenosis, and FFR=0.75 is also well recognized as the cutoff value for re-S
Correlates of Clinical Restenosis Following Intracoronary Implantation of Drug-Eluting Stents
The American Journal of Cardiology, 2007
Despite significant decreases in restenosis and repeated intervention achieved using drugeluting stents (DESs), the benefit has not been homogenous across all patient and lesion subsets. Identification of correlates of DES restenosis may allow a differing management approach and lead to improved patient outcomes. The study population consisted of 3,535 consecutive patients (5,046 lesions) who underwent successful sirolimus-or paclitaxeleluting stent implantation for >1 native coronary artery or bypass graft lesion from April 2003 to September 2006. From this cohort, 197 patients (237 lesions) were identified to have in-stent restenosis (ISR) requiring revascularization within 12 months of stent implantation. This group was compared with the remainder of the patient population. Logistic regression analysis was performed to identify independent predictors of DES ISR. Independent correlates of DES ISR using multivariate analysis included both clinical and procedural factors. Clinical predictors were age, hypertension, and unstable angina. Procedural predictors were left anterior descending artery intervention, number of stents implanted, stented length/lesion, and lack of intravascular ultrasound guidance. Implantation of >3 stents was associated with a significantly higher restenosis risk (9.7% vs 5.1%; p ؍ 0.0003). A 10-mm increase in stented length was associated with an adjusted odds ratio of 1.18 (95% confidence interval 1.03 to 1.35). Diabetes, stent diameter, and stent type were found not to be predictive of DES ISR. In conclusion, correlates of DES ISR included both clinical and procedural factors. Limiting the number of stents and stented length, in addition to intravascular ultrasound guidance, may minimize DES ISR.
The American Journal of Cardiology, 2008
Patterns of in-stent restenosis (ISR) after drug-eluting stent (DES) implantation and outcomes after treatment have not been studied systematically in all comers. We compared patterns of ISR and outcomes of repeated percutaneous coronary intervention in consecutive patients with DES-ISR. A total of 137 patients with 182 lesions underwent repeated percutaneous coronary intervention for DES-ISR at Columbia University Medical Center from August 2004 to April 2006. DES-ISR was treated with repeated DES placement in 84% of patients and balloon angioplasty in 16%. There was 1 stent thrombosis at 30 days, and at 1 year, major adverse cardiac events occurred in 10% of patients, driven primarily by an 8% rate of target-lesion revascularization. After exclusion of 12 patients with multiple ISR lesions, data were further analyzed from 125 patients with 152 DES-ISR lesions, of which 118 were originally treated with sirolimus-eluting stents and 34 were treated with paclitaxel-eluting stents (PES-ISR). Baseline features were well matched between the 2 groups, except that patients with PES-ISR were older. A focal pattern of ISR was observed in 69.5% of patients overall. However, patients originally treated with a PES had a significantly higher frequency of diffuse-intrastent ISR in comparison with sirolimuseluting stent ISR (30.3% vs 13.6%, p ؍ 0.03). In conclusion, the pattern of ISR in most DES-ISR in this unselected patient population was focal, with higher rates of diffuse intrastent restenosis seen with PES-ISR. Treatment with either repeated DES implantation or balloon angioplasty for DES-ISR was safe and associated with low overall rates of target-lesion revascularization and major adverse cardiac events at 1 year.