title: Evaluation of a policy of selective drug-eluting stent implantation for patients at high risk of restenosis.
abstract: Drug-eluting stent (DES) deployment during percutaneous coronary intervention (PCI) has reduced target-vessel revascularisation rates (TVR). The selective use of DES in patients at highest risk of restenosis may allay concerns about universal compliance of dual antiplatelet therapy for one year, and potentially reduce costs. If this strategy achieved acceptably low TVR rates, such an approach could be attractive. Late clinical outcomes were examined in 2115 consecutive patients (mean age 63±12 years, 75% male, 22% diabetics) who underwent PCI in the first three years from October 2003, after commencing the following selective criteria for DES use: left main stenosis; ostial lesions of major epicardial arteries; proximal LAD lesions; lesions≥20mm in length with vessel diameter≤3.0mm; lesions in vessels≤2.5mm; diabetics with vessel(s)≤3.0mm; and in-stent restenosis. Among patients undergoing PCI, 2075 (98%) patients received stents (29%≥1 DES and 71% bare metal stent [BMS]), and among those who received DES, there was a 92% compliance with these criteria. There were no differences in clinical outcomes between the two stent groups except for definite stent thrombosis, which occurred in 2% after DES, and 0.6% after BMS at one year (p=0.002). With BMS, large coronary arteries (≥3.5mm), intermediate (3-3.49mm) and small arteries (<3mm) in diameter had a TVR rate at one year of 3.6%, 7.2% and 8.2% respectively (p=0.005). It is possible to use selective criteria for DES while maintaining low TVR rates. The TVR rate with BMS was low in those with stent diameters≥3.5mm. The higher DES stent thrombosis rate reflects first generation DES use, though whether routine second generation DES use reduces these rates needs confirmation.
authors: Department of Cardiology, Liverpool Hospital, South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia.
authors: Ibrahim M
authors: IM
authors: Shugman
authors: Hanan
authors: H
authors: Idris
authors: Krishna Kishor
authors: KK
authors: Kadappu
authors: Phong
authors: P
authors: Nguyen
authors: David
authors: D
authors: Taylor
authors: Rohan
authors: R
authors: Rajaratnam
authors: Dominic
authors: D
authors: Leung
authors: Andrew P
authors: AP
authors: Hopkins
authors: Sidney
authors: S
authors: Lo
authors: Craig P
authors: CP
authors: Juergens
authors: John K
authors: JK
authors: French
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003331:Coronary Vessels / Q000601:surgery; D003365:Costs and Cost Analysis; D054855:Drug-Eluting Stents / Q000592:standards*; D005260:Female; D006083:Graft Occlusion, Vascular / Q000191:economics / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000191:economics / Q000379:methods* / Q000592:standards*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D011050:Policy Making
chemical_list: D010975:Platelet Aggregation Inhibitors