Impact of stent diameter and length on in-stent restenosis after DES vs BMS implantation in patients needing large coronary stents-A clinical and health-economic evaluation.
OBJECTIVE
The British National Institute of Clinical Excellence (NICE) guidelines recommend to use drug-eluting stents (DES) instead of bare-metal stents (BMS) only in lesions >15 mm in length or in vessels <3 mm in diameter. We analyzed the impact of stent length and stent diameter on in-stent restenosis (ISR) in the BASKET-PROVE study population and evaluated the cost-effectiveness of DES compared to BMS.


RESULTS
The BASKET-PROVE trial compared DES vs BMS in large coronary arteries (≥3 mm). We calculated incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves with regard to quality-adjusted life years (QALYs) gained and target lesion revascularizations (TLRs) avoided. A total of 2278 patients were included in the analysis. A total of 74 ISR in 63 patients were observed. In-stent restenosis was significantly more frequent in segments treated with a BMS compared to segments treated with a DES (5.4% vs 0.76%; P<.001). The benefit of a DES compared to a BMS regarding ISR was consistent among the subgroups of stent length >15 mm and ≤15 mm, respectively. With the use of DES in short lesions, there was only a minimal gain of 0.005 in QALYs. At a threshold of 10 000 CHF per TLR avoided, DES had a high probability of being cost-effective.


CONCLUSIONS
In the BASKET-PROVE study population, the strongest predictor of ISR is the use of a BMS, even in patients in need of stents ≥3.0 mm and ≤15 mm lesion length and DES were cost-effective. This should prompt the NICE to reevaluate its recommendation to use DES instead of BMS only in vessels <3.0 mm and lesions >15 mm length.
Department of Cardiology, Triemlispital Zurich, Zurich, Switzerland.
Rainer
R
Zbinden
Department of Cardiology, University Hospital Basel, Basel, Switzerland.
Stefanie
S
von Felten
Department of Cardiology, University Hospital Basel, Basel, Switzerland.
Bastian
B
Wein
Department of Cardiology, Triemlispital Zurich, Zurich, Switzerland.
David
D
Tueller
Department of Cardiology, Triemlispital Zurich, Zurich, Switzerland.
David J
DJ
Kurz
Department of Cardiology, Triemlispital Zurich, Zurich, Switzerland.
Ivano
I
Reho
Department of Cardiology, Gentofte Hospital, Hellerup, Denmark.
Soren
S
Galatius
Department of Cardiology, University Hospital Innsbruck, Innsbruck, Austria.
Hannes
H
Alber
Department of Cardiology, University Hospital Basel, Basel, Switzerland.
David
D
Conen
Department of Cardiology, University Hospital Basel, Basel, Switzerland.
Matthias
M
Pfisterer
Department of Cardiology, University Hospital Basel, Basel, Switzerland.
Christoph
C
Kaiser
Department of Cardiology, Triemlispital Zurich, Zurich, Switzerland.
Franz R
FR
Eberli
D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000191:economics / Q000628:therapy; D023903:Coronary Restenosis / Q000000981:diagnostic imaging / Q000191:economics / Q000209:etiology / Q000517:prevention & control; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D054855:Drug-Eluting Stents / Q000191:economics; D017048:Health Care Costs; D053208:Kaplan-Meier Estimate; D008670:Metals / Q000191:economics; D018803:Models, Economic; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation; D011474:Prosthesis Design; D019057:Quality-Adjusted Life Years; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents / Q000191:economics; D013997:Time Factors; D016896:Treatment Outcome
D008670:Metals
Bare-metal stents; Cost-effectiveness; Drug-eluting stents; In-stent restenosis