Vascular response after implantation of coated and non-coated coronary stents

Het doel van dit proefschrift was het bestuderen van de vaatwandreactie na interventies in de kransslagader. Hierbij werd gekeken naar acute en chronische vaatwandbeschadiging, endotheeldysfunctie en naar het gedrag van de nieuwste generatie stents, de zogenaamde “drug-eluting stents” (DES), waarbij na implantatie gedurende een bepaalde tijd langzaam een medicijn diffundeert uit de stentcoating ter voorkoming van in-stent restenose. Deze medicijnen worden namelijk gerelateerd aan vertraagde genezing van de beschadigde vaatwand, wegens de sterke anti-proliferatieve werking van deze medicijnen. Het eerste deel van het proefschrift concentreert zich op de vaatwandbeschadiging die ontstaat door de interventie. Hoofdstuk 2 Beschrijft de vier fasen van de wondgenezing na het plaatsen van een stent, nl. de vroege trombotische respons, gevolgd door de recruteerfase gekenmerkt door het aantrekken van cellen, vervolgens de proliferatieve fase en tot slot de helingsfase. In hoofdstuk 3 wordt aangetoond dat de initiele vaatwandschade de eerste weken na de interventie zelfs nog toeneemt. In een varkensmodel worden twee verschillende stenttypes onderzocht in de kransslagader. Persisterende ontstekingsreactie en het verschil in stentontwerp lijken van invloed op de vaatwandschade en de helingsrespons. Voor de goede resultaten van de nieuwe DES was intracoronaire bestralingstherapie (brachytherapy) de meest effectieve therapie voor de behandeling van restenose in de stent. Daarnaast werd ook onderzocht of brachytherapy deze in-stent restenose zou kunnen voorkomen. De langetermijn resultaten bleken teleurstellend en vooral late stenttromboses werd frequent gezien, resulterend in een afsluiting van het vat. Hoofdstuk 4 beschrijft een patient waarbij 5 jaar na de behandeling en preventieve brachytherapie het bloedvat alsnog afgesloten raakt, terwijl het bij de 3-jaarscontrole nog fraai open was. De sterk vertraagde wondgenezing door de bestraling speelt waarschijnlijk een rol in deze erg late complicaties. In de begintijd van de DES waren er alleen maar relatief kleine maten beschikbaar. Om toch iedereen te kunnen laten profiteren van deze goede stents werden ze ook gebruikt in grotere vaten. Vervolgens werd de stent met een grotere balloon nagerekt. Hoofdstuk 5 laat zien dat dit kan leiden tot een breuk in de stent en re-stenose. Door de scherpe gebroken stentstruts, beschadigde polymeercoating en ter plekke minder effectieve dosering van het medicament dat re-stenose tegen moet gaan, kan deze stentbreuk alsnog leiden tot re-stenose, zelfs in grote vaten waar dit normaliter zelden voorkomt. Het tweede deel van dit proefschrift bestudeert de endotheelfunctie na interventies in de kransslagader. In hoofdstuk 6 werd vaatwandpermeabiliteit as marker van herstel van een volgroeide endotheellaag bestudeerd, zowel na ballonangioplastiek als na stenting, zowel vroeg als laat na de behandeling. Abnormale permeabiliteit kon worden aangetoond tot 3 maanden na de behandeling, waarbij dit meer uitgesproken was na stenting dan na ballonangioplastiek. Dit impliceert incompleet herstel van de endotheellaag. Hierbij konden karakteristieke morfologische veranderingen van de endotheelcellen worden aangetoond. Zoals boven reeds genoemd is de wondgenezing vertraagd na brachytherapie. In hoofdstuk 7 werd onderzocht of ernstiger endotheeldysfunctie aangetoond kon worden 6 maanden na stenting en brachytherapie dan na stenting zonder brachytherapie. In beide groepen was na 6 maanden de endotheelfunctie nog abnormaal, zoals ook reeds eerder aangetoond door Caramori et al. na stenting, maar een verschil tussen stent of stent en brachytherapie kon niet aangetoond worden. In hoofdstuk 8 werd de endotheelfunctie onderzocht 6 maanden na implantatie van de nieuwe generatie stents, de DES, en in dit geval de sirolimus-gecoate stent (SES). Dit leidde tot de opmerkelijke bevinding dat 6 maanden na de behandeling de endotheelfunctie ernstig gestoord was na implantatie van de SES, terwijl dit veel minder het geval was na een ongecoate stent. Dit is opvallend aangezien de klinische resultaten met inmiddels een follow-up van ruim 3 jaar uitstekende resultaten laten zien van deze stent. Deze bevinding zal moeten worden bevestigd in een veel grotere groep patienten, maar het roept wel op tot waakzaamheid en langdurige follow-up. Hoewel in grote studies nooit hard aangetoond, is er toch een vermoeden op een iets verhoogde kans op stenttrombose bij het gebruik van DES, vooral na het voortijdig stoppen van bloedplaatjesaggregatieremmers. Het langdurig gebruik van dubbele plaatjesaggregatieremmende medicatie is inmiddels reeds gebruikelijk, maar misschien zou een ACE-remmer na stenting ook standaard moeten worden net als cholesterolverlagende medicatie. Beide medicijnen hebben bewezen gunstig effect op atheroscleroseprogressie en een gunstig effect op het endotheel. In hoofdstuk 9 werd de relatie bestudeerd tussen locale endotheelfunctie en shear stress (schuifspanning). Tot nu toe is alleen in “in vitro” onderzoeken een relatie tussen low shear stress en endotheeldysfunctie aangetoond. Door gebruik te maken van wiskundige rekenmodellen konden 3D reconstructies worden gemaakt van de coronairvaten uit angiografische plaatjes en door middel van correlatie met gemeten bloedstroomsnelheden tijdens acetylcholineinfusie in de kransslagaderen, kon de relatie tussen shear stress en endotheeldysfunctie (vaatvernauwing op acetylcholine) worden bestudeerd. Gebiedjes met een lage shear stress van < 1,3 Pa gaven een significant grotere vaatvernauwing na acetylcholine vergeleken met gebiedjes met een hogere shear stress. Het is voor de eerste keer dat dit in vivo is aangetoond. Het derde deel van dit proefschrift concentreert zich op gecoate stents en DES. Hoofdstuk 10 beschrijft de resultaten van het gebruik van heparine-gecoate stents in kransslagaders van biggen. Deze preklinische studie leidde tot de bekende klinische studies, de BENESTENT 2 pilot en trial. Hierbij werd de veiligheid van de heparine­gecoate stent aangetoond zonder een verhoogd risiko op stenttrombose met alleen nabehandeling met twee verschillende plaatjesaggregatieremmende medicamenten. Dit is 8 jaar later nog steeds de gebruikelijke therapie. De afgelopen 10 jaren zijn nog diverse studies verricht met verschillende soorten heparine-gecoate stents om het risiko op stenttrombose te minimaliseren en het percentage in-stent restenose te verminderen. Dit eerste was succesvol met zelfs trombosepercentages ver onder de 0,5 % ten opzichte van ongeveer 1 % in metalen stents. Helaas is een significant reductie van in-stent restenose nooit aangetoond. Hoofdstuk 11 geeft een overzicht van deze studies. De boven reeds genoemde DES hebben inmiddels zeer goede resultaten laten zien in grote studies en worden in snel toenemende mate gebruikt in plaats van metalen stents. Tot nu toe zijn twee van dit soort stents in grote trials onderzocht en commercieel op grote schaal verkrijgbaar, nl. de sirolimus-eluting stent (SES) (Cypher, Cordis Co, Warren, NJ, USA) en de paclitaxel-eluting stent (PES) (Taxus, Boston Scientific, Galway, Ireland). Hoofdstuk 12 geeft een overzicht van de preklinische en klinische studies met diverse DES tot februari 2004. In Hoodstuk 13 worden de eerste 186 patienten beschreven die in het ErasmusMC werden behandeld met een SES voor een acuut hartinfarct. Hoewel een patient met een acuut hartinfarct een duidelijk verhoogde stollingsneiging van zijn bloed heeft in de acute fase, bleek het gebruik van de SES ook in deze setting veilig en zonder verhoogde risiko’s op stenttrombose. Ook bleek dat patienten die met een SES behandeld werden vrijwel nooit terug hoefden te komen voor een herinterventie in het behandelde vat gedurende een follow-up van 300 dagen (1,1% vs. 8,2 % voor patienten behandeld met een metalen stent). In hoofdstuk 14 werd de andere DES nl. de PES geevalueerd voor dezelfde indicatie. Ook deze stent liet goede resultaten zien, echter er werden enkele patienten teruggezien met stenttrombose (2,9 %). De helft van deze patienten waren in de acute fase behandeld voor een afsluiting op een vertakking in de kransslagader. Hierbij waren beide takken gestent, en hoewel deze getallen erg klein zijn, zou dit mogelijk een verhoogde stenttrombose kans geven. Late stenttromboses werden niet gezien en na 1 jaar was er geen significant verschil in effectiviteit tussen de SES en de PES. Conclusie: Dit proefschrift laat zien dat de vaatwand beschadigd raakt tijdens de behandeling van vernauwingen in de kransslagader met ballonangioplastiek of stentplaatsing. Deze beschadiging kan zelfs nog toenemen in de eerste weken na stentplaatsing. Dit wordt gevolgd door een genezingsreactie met vorming van een neointima. Bij excessieve schade is de kans groter op in-stent restenose door meer neointimaproliferatie. Endotheeldysfunctie is nog maanden na de interventie in het bloedvat aantoonbaar. Hoewel deze genezingsfase wordt vertraagd door bestralingstherapie kon na 6 maanden geen verschil in endotheeldysfunctie worden aangetoond in bestraalde patienten tov niet-bestraalde patienten. Daar stond tegenover dat in patienten die een SES ontvingen de endotheelfunctie na 6 maanden nog sterk gestoord was. Ook kon in deze patientengroep een relatie aangetoond worden tussen gebieden van lage schuifspanning (shear stress) en locale endotheeldysfunctie. Ondanks dit zijn de middellange termijn resultaten van SES en PES uitstekend en kon zelfs in de zeer trombogene setting van het acuut hartinfarct geen verhoogde neiging tot late stenttrombose aangetoond worden, als uiting van vertraagde vaatwandgenezing. Desalniettemin is vertraagde wondgenezing, gepaard gaand met langdurige endotheeldysfunctie reden tot enige zorg. Ondanks de forse verlenging van de behandelduur met twee bloedplaatjesaggregatieremmers is de incidentie van stenttrombose vergelijkbaar met ongecoate stents en het optreden ervan minder voorspelbaar. Het lijkt verstandig na het opheffen van de belangrijke vernauwing meer aandacht te besteden aan de kwaliteit van het endotheel. Dit zou misschien kunnen door een groter gebruik van ACE-remmers na de PCI alsmede door aggresieve cholesterolverlaging.The aim of this thesis was to study vascular response to coronary interventions. This involved study of vessel wall injury, both acute and chronic, endothelial dysfunction and the performance of drug-eluting stents in clinical practice, as they are associated with delayed vascular healing due to their anti-proliferative capacity. The first part of the thesis is focussing on the vascular wall trauma, caused by the interventions. Chapter 2 describes the four phases of wound healing after intracoronary stenting, i.e. the early thrombotic response, followed by the recruitment phase with cellular infiltration, the proliferative phase and the final healing phase. In chapter 3 it is shown that the vessel wall injury inflicted in the acute phase by stenting is even increasing in the weeks after the intervention. Two very different stent types were studied in the porcine coronary model and the difference in response suggests that persistent inflammatory response and stent design may influence the chronic injury and healing response. Intracoronary irradiation therapy (brachytherapy) was the most effective therapy for treating in-stent restenosis until the recent favourable outcomes with drug-eluting stents. Brachytherapy was also investigated as adjunctive therapy directly after stenting or balloon angioplasty to prevent the occurrence of restenosis. However, long-term results are disappointing and a high percentage of late thrombotic occlusion has been reported. In chapter 4 a case-report is presented with late occlusion five years after balloon angioplasty and adjunctive brachytherapy, while 3 year follow-up angiography had shown a patent vessel! Impaired healing response of the vessel wall after radiation therapy is thought to be the cause of these late (thrombotic) occlusions. Chapter 5 shows the sequelae of the early drug-eluting stent period, when the largest available stent size was 3.0 mm. To achieve acceptable stent apposition in large coronary vessels, stents were up-sized with larger balloons. This can lead to stent strut fracture and as shown in this case the combination of less local drug elution and the direct trauma of the broken stent struts as well as damage to the polymer can lead to restenosis, even in large vessels and with the use of drug-eluting stents. The second part of this thesis is focussing on endothelial dysfunction after percutaneous coronary interventions (PCI). In chapter 6 vascular permeability as a parameter of regeneration of a mature endothelial lining after balloon angioplasty or stenting was investigated, both early and late after the intervention. Dye-exclusion tests showed persistent vascular permeability up to 3 months after the intervention, being the most pronounced in the stented vessels. This indicates immature endothelial functional recovery and this was correlated with distinct morphologic characteristics, such as endothelial retraction, the expression of surface folds and the adhesion of leukocytes. Brachytherapy is associated with a delayed vascular healing response. In chapter 7 we investigated whether more endothelial dysfunction could be demonstrated in patients treated 6 months before with stenting and adjunctive brachytherapy or no brachytherapy. In both groups, endothelial function was still abnormal after 6 months, like shown before by Caramori et al. in bare stents, but no difference could be demonstrated. Investigating endothelial function 6 months after drug-eluting stent implantation in chapter 8 led to the remarkable observation that endothelial function was severely disturbed, while in the control group no significant paradoxal vasoconstriction ( as a sign of endothelial dysfunction) could be demonstrated. This is not in accordance with the excellent clinical results up to three year after drug-eluting stent implantation. This outcome should be investigated in a larger patient population, but is reason for some concern and may be related to the slight increase in stent thrombosis seen after drug-eluting stent implantation, particularly late stent occlusions. If confirmed, adjunctive medical therapy like ACE-inhibitors as well as already advised cholesterol-lowering therapy for all patients after drug­eluting stents should be considered, next to the already implemented prolonged use of double anti-platelet therapy. The subset of patients from the study reported in chapter 8 was used to study the relation between local endothelial function and shear stress in chapter 9. Low shear stress has been correlated to endothelial dysfunction but this has only been shown in vitro. Using sophisticated mathematical calculations, 3D reconstructions of the coronary segments distal to the implanted stents were made. Incorporating coronary flow velocity data and studying the patients after intracoronary acetylcholine infusions, correlations between local shear stress and local endothelial dysfunction (vasoconstriction) could be found. In regions with a shear stress of less than 1.3 Pa, a significantly larger vasoconstrictive response to acetylcholine could be seen compared to areas with shear stress of 1.3 Pa or more (normal to high shear stress). It is for the first time that such a correlation could be demonstrated in vivo. The third part of this thesis is focussing on coated and drug-eluting stents. Chapter 10 reports the findings of the use of a heparin-coated stent in porcine coronary arteries. This preclinical study led to the clinical BENESTENT 2 pilot and trial, showing a very low risk of stent thrombosis, despite a progressively milder anti-coagulant regime, ending with dual-platelet therapy, without post-procedural heparin. Today this is still the clinical practice. Over the last 10 years further attempts have been undertaken with different heparin stent- coatings to minimize the risk of stent thrombosis and reduce the incidence of in-stent restenosis. Chapter 11 provides an update on those attempts, highlighting three different heparin-coatings, the HepacoatTM, the HepamedTM and the CorlineTM coating. Clinical trials have shown very low rates of subacute stent thrombosis of 0.2 %. The average incidence of subacute stent thrombosis in bare metal stent is around 1 %. However, the other goal to reduce the rate of in-stent restenosis has not been reached and no significant difference has emerged from the different trials. There is a nice for heparin-coated stents in highly thrombotic subsets of patients or patients with a contraindication for prolonged antiplatelet therapy, but availability of the stents has become a problem. After attempts with passive stent coatings newer concepts with drug-elution from a stent­based polymer, or even without polymer were investigated. This is a fast evolving field of research which has led sofar to two commercially available drug-eluting stents with excellent clinical results in multiple large trials, the sirolimus-eluting stent (SES) (Cypher, Cordis Co, Warren, NJ, USA) and the paclitaxel-eluting stent (PES) (Taxus, Boston Scientific, Galway, Ireland). Next to these stents, multiple drug-eluting stents are in the pre-clinical or clinical testing phase. Chapter 12 is providing an update up to February 2004 of this field. In chapter 13 the first registry results are reported of the use of SES in the highly thrombotic environment of patients with an acute myocardial infarction. Concerns of higher risk of stent thrombosis in drug-eluting stents have been expressed multiple times and though it never has been substantiated, this fear has led to restrictive use in acute myocardial infarction. In this series of 186 consecutive patients no stent thrombosis was diagnosed and only 1.1 % of patients needed target vessel reintervention at 300 days follow-up compared to 8.2 % in the bare stent group in this study. Chapter 14 investigated the safety of the PES for the same indication of primary PCI for acute myocardial infarction. PES is also effective, but the slightly higher risk of subacute thrombosis of 2.9 % raises some concern. Half of these stent thromboses were seen in stented bifurcation lesions. This suggests that bifurcation stenting should be avoided in the setting of an acute myocardial infarction if possible and bifurcation treatment should be kept as simple as possible. Late stent thrombosis after 30 days was not seen, which is very reassuring. In Conclusion this thesis demonstrated that vessel wall injury occurs during coronary intervention, that this vessel wall injury can even increase after the acute injury in the case of stenting and that this injury leads to neointimal proliferation. Endothelial dysfunction is still present months after the intervention, but no worse endothelial function could be demonstrated late after brachytherapy compared to no brachytherapy. In contrast, after SES implantation severe endothelial dysfunction was still detectable after 6 months. A correlation could be found between local endothelial dysfunction and areas of low shear stress. Despite this, SES and PES show excellent intermediate-term clinical results and no late stent thrombosis could be found in patients treated during acute myocardial infarction. However, delayed vascular healing with prolonged endothelial dysfunction is reason for some concern and despite extended duration of double anti-platelet therapy, stent thrombosis rates are similar to those in bare stents and the timing is less predictable. More attention towards improving endothelial function after intervention of the culprit lesion seems advisable. May be this can be achieved by adjunctive medication like ACE-inhibitors and aggressive cholesterol lowering

Everolimus- and sirolimus-eluting stents in patients with and without ST-segment elevation myocardial infarction

Aims Everolimus-eluting stents (EES) were superior to sirolimus-eluting stents (SES) in a dedicated myocardial infarction trial, a finding that was not observed in trials with low percentages of ST-elevation myocardial infarction (STEMI). Therefore, this study sought to investigate the influence of clinical presentation on outcome after EES and SES implantation. Methods A pooled population of 1602 randomised patients was formed from XAMI (acute MI trial) and APPENDIXAMI (all-comer trial). Primary outcome was cardiac mortality, MI and target vessel revascularisation at 2 years. Secondary endpoints included definite/probable stent thrombosis (ST). Adjustment was done using Cox regression. Results In total, 902 EES and 700 SES patientswere included, of which 44%STEMI patients (EES 455; SES 257) and 56% without STEMI (EES 447; SES 443). In the pooled population, EES and SES showed similar outcomes during followup. Moreover, no differences in the endpoints were observed after stratification according to presentation. Although a trend toward reduced early definite/probable ST was observed in EES compared with SES in STEMI patients, long-term ST rates were low and comparable. Conclusions EES and SES showed a similar outcome during 2-year follow-up, regardless of clinical presentation. Longterm safety was excellent for both devices, despite wide inclusion criteria and a large sub-population of STEMI patients

Clinical, angiographic, and procedural predictors of angiographic restenosis after sirolimus-eluting stent implantation in complex patients

BACKGROUND: The factors associated with the occurrence of restenosis after sirolimus-eluting stent (SES) implantation in complex cases are currently unknown. METHODS AND RESULTS: A cohort of consecutive complex patients treated with SES implantation was selected according to the following criteria: (1) treatment of acute myocardial infarction, (2) treatment of in-stent restenosis, (3) 2.25-mm diameter SES, (4) left main coronary stenting, (5) chronic total occlusion, (6) stented segment >36 mm, and (7) bifurcation stenting. The present study population was composed of 238 patients (441 lesions) for whom 6-month angiographic follow-up data were obtained (70% of eligible patients). Significant clinical, angiographic, and procedural predictors of post-SES restenosis were evaluated. Binary in-segment restenosis was diagnosed in 7.9% of lesions (6.3% in-stent, 0.9% at the proximal edge, 0.7% at the distal edge). The following characteristics were identified as independent multivariate predictors: treatment of in-stent restenosis (OR 4.16, 95% CI 1.63 to 11.01; P<0.01), ostial location (OR 4.84, 95% CI 1.81 to 12.07; P<0.01), diabetes (OR 2.63, 95% CI 1.14 to 6.31; P=0.02), total stented length (per 10-mm increase; OR 1.42, 95% CI 1.21 to 1.68; P<0.01), reference diameter (per 1.0-mm increase; OR 0.46, 95% CI 0.24 to 0.87; P=0.03), and left anterior descending artery (OR 0.30, 95% CI 0.10 to 0.69; P<0.01). CONCLUSIONS: Angiographic restenosis after SES implantation in complex patients is an infrequent event, occurring mainly in association with lesion-based characteristics and diabetes mellitus

Effectiveness of the sirolimus-eluting stent in the treatment of patients with a prior history of coronary artery bypass graft surgery

Objective: Percutaneous coronary intervention in patients with a history of previous coronary artery bypass grafting (CABG) is associated with an increased rate of subsequent adverse events compared to those without prior CABG. We evaluated the impact of utilizing the sirolimus-eluting stent (SES) in this high-risk population. Methods: Since April 2002, SES implantation was utilized as the default strategy for all percutaneous procedures in our hospital. Consecutive patients with a history of previous CABG and de novo lesions (n=47) treated exclusively with SES, were compared to 66 patients who received bare stents in the 6-month period just before SES introduction. Results: There were no significant differences between the groups (SES and bare stent) with respect to baseline clinical or lesion characteristics. The only difference between the groups related to the nominal diameter of stent utilized, which was smaller in the SES group than the bare stent group. (The maximum diameter of SES available was 3.0 mm). At 1 year, the cumulative incidence of major adverse events (defined as death, myocardial infarction, or target vessel revascularization) was significantly lower in the SES group than the bare stent group [8.5 versus 30.3%, hazard ratio 0.37 (95% confidence interval 0.15-0.91); P=0.03]. Conclusions: The utilization of the sirolimus-eluting stent for percutaneous intervention in a high-risk population with a history of previous CABG surgery is associated with a significant reduction in the rate of major adverse cardiac events at 1 year

Recommendations for the use of bioresorbable vascular scaffolds in percutaneous coronary interventions

Background To eliminate some of the potential late limitations of permanent metallic stents, the bioresorbable coronary stents or ‘bioresorbable vascular scaffolds’ (BVS) have been developed. Methods We reviewed all currently available clinical data on BVS implantation. Results Since the 2015 position statement on the appropriateness of BVS in percutaneous coronary interventions, several large randomised trials have been presented. These have demonstrated that achieving adequate 1 and 2 year outcomes with these first-generation BVS is not straightforward. These first adequately powered studies in non-complex lesions showed worse results if standard implan- tation techniques were used for these relatively thick scaffolds. Post-hoc analyses hypothesise that outcomes similar to current drug-eluting stents are still possible if aggressive lesion preparation, adequate sizing and high-pressure postdilatation are implemented rigorously. As long as this has not been confirmed in prospective studies the usage should be restricted to experienced centres with continuous outcome monitoring. For more complex lesions, results are even more disappointing and usage should be discouraged. When developed, newer generation scaffolds with thinner struts or faster resorption rates are expected to improve outcomes. In the meantime prolonged dual antiplatelet therapy (DAPT, beyond one year) is recommended in an individu-alised approach for patients treated with current generation BVS. Conclusion The new 2017 recommendations downgrade and limit the use of the current BVS to experienced centres within dedicated registries using the updated implantation protocol and advise the prolonged usage of DAPT. In line with these recommendations the manufacturer does not supply devices to the hospitals without such registries in place

Very long sirolimus-eluting stent implantation for de novo coronary lesions.

Long-length stenting has a poor outcome when bare metal stents are used. The safety and efficacy of the sirolimus-eluting stent (SES) in long lesions has not been evaluated. Therefore, the aim of the present study was to evaluate the clinical and angiographic outcomes of SES implantation over a very long coronary artery segment. Since April 2002, all patients treated percutaneously at our institution received a SES as the device of choice as part of the Rapamycin Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. During the RESEARCH registry, stents were available in lengths of 8, 18, and 33 mm. The present report includes a predefined study population consisting of patients treated with >36-mm-long stented segments. Patients had a combination of >or=2 overlapping stents at a minimum length of 41 mm (i.e., one 33-mm SES overlapping an 8-mm SES) to treat native de novo coronary lesions. The incidence of major cardiac adverse events (death, nonfatal myocardial infarction, and target lesion revascularization) was evaluated. The study group comprised 96 consecutive patients (102 lesions). Clinical follow-up was available for all patients at a mean of 320 days (range 265 to 442). In all, 20% of long-stented lesions were chronic total occlusions, and mean stented length per lesion was 61.2 +/- 21.4 mm (range 41 to 134). Angiographic follow-up at 6 months was obtained in 67 patients (71%). Binary restenosis rate was 11.9% and in-stent late loss was 0.13 +/- 0.47 mm. At long-term follow-up (mean 320 days), there were 2 deaths (2.1%), and the overall incidence of major cardiac events was 8.3%. Thus, SES implantation appears safe and effective for de novo coronary lesions requiring multiple stent placement over a very long vessel segment

Antithrombotic therapy in patients undergoing TAVI: An overview of Dutch hospitals

Purpose To assess current antithrombotic treatment strategies in the Netherlands in patients undergoing transcatheter aortic valve implantation (TAVI). Methods For every Dutch hospital performing TAVI (n =14) an interventional cardiologist experienced in performing TAVI was interviewed concerning heparin, aspirin, thienopyridine and oral anticoagulation treatment in patients undergoing TAVI. Results The response rate was 100 %. In every centre, a protocol for antithrombotic treatment after TAVI was available. Aspirin was prescribed in all centres, concomitant clopidogrel was prescribed 13 of the 14 centres. Duration of concomitant clopidogrel was 3 months in over twothirds of cases. In 2 centres, duration of concomitant clopidogrel was based upon type of prosthesis: 6 months versus 3 months for supra-annular and intra-annular prostheses, respectively. Conclusions Leaning on a small basis of evidence and recommendations, the antithrombotic policy for patients undergoing TAVI is highly variable in the Netherlands. As a standardised regimen might further reduce haemorrhagic complications, large randomised clinical trials may help to establish the most appropriate approach