Clinical and economic impact of diabetes mellitus on percutaneous and surgical treatment of multivessel coronary disease patients: insights from the Arterial Revascularization Therapy Study (ARTS) trial.

BACKGROUND: Our aims were to compare coronary artery bypass grafting (CABG) and stenting for the treatment of diabetic patients with multivessel coronary disease enrolled in the Arterial Revascularization Therapy Study (ARTS) trial and to determine the costs of these 2 treatment strategies. METHODS AND RESULTS: Patients (n=1205) were randomly assigned to stent implantation (n=600; diabetic, 112) or CABG (n=605; diabetic, 96). Costs per patient were calculated as the product of each patient's use of resources and the corresponding unit costs. Baseline characteristics were similar between the groups. At 1 year, diabetic patients treated with stenting had the lowest event-free survival rate (63.4%) because of a higher incidence of repeat revascularization compared with both diabetic patients treated with CABG (84.4%, P<0.001) and nondiabetic patients treated with stents (76.2%, P=0.04). Conversely, diabetic and nondiabetic patients experienced similar 1-year event-free survival rates when treated with CABG (84.4% and 88.4%). The total 1-year costs for stenting and CABG in diabetic patients were $12 855 and $16 585 (P<0.001) and in the nondiabetic groups, $10 164 for stenting and $13 082 for surgery. CONCLUSIONS: Multivessel diabetic patients treated with stenting had a worse 1-year outcome than patients assigned to CABG or nondiabetics treated with stenting. The strategy of stenting was less costly than CABG, however, regardless of diabetic status.

Intravascular ultrasound assessment of the presence of vascular remodeling in diseased human saphenous vein bypass grafts.

Remodeling occurs in diseased human coronary arteries; however, reports of remodeling in diseased autologous saphenous vein bypass graft (SVG) stenoses are inconsistent. Preintervention intravascular ultrasound and quantitative coronary angiography were used to study 104 SVG stenoses in 93 consecutive patients. Lesion site and proximal and distal reference segment measurements included vein graft, external elastic membrane, lumen, wall (vein graft minus lumen), and plaque (external elastic membrane minus lumen) areas. Three indexes of remodeling were assessed: (1) lesion site SVG (or external elastic membrane) area was compared with the average reference segment, (2) SVG area was correlated with the wall area and external elastic membrane area was correlated with the plaque area, and (3) the impact of excess plaque accumulation (at the stenosis compared with the reference segment) on lumen compromise was calculated. Overall, the ratio of lesion/reference vein graft area was 1.07 +/- 0.25; however, 23 lesions were classified as negative remodeling (ratio <0.9), 37 as intermediate remodeling (ratio between 0.9 and 1.1), and 44 as positive remodeling (ratio >1.1). Reference segment vein graft area correlated with wall area (r = 0.906, p <0.0001), and external elastic membrane area correlated with plaque area (r = 0.703, p <0.0001). Similarly, lesion site vein graft area correlated with wall area (r = 0.978, p <0.0001), and external elastic membrane area correlated with plaque area (r = 0.961, p <0.0001). The regression line relating delta lumen area to delta wall area was y = -0.22 x - 6.2 (r = 0.451, p <0.0001) and the regression line relating delta lumen to delta plaque area was y = -0.47 x - 4.5 (r = 0.572, p <0.0001). (A slope of 0 would indicate perfect positive remodeling and a slope of 1.0 no positive remodeling.) Diseased SVGs undergo positive and negative remodeling similar to native coronary arteries.

One-year follow-up after intravascular ultrasound assessment of moderate left main coronary artery disease in patients with ambiguous angiograms.

OBJECTIVES: The purpose of this study was to correlate angiographic and intravascular ultrasound (IVUS) findings in left main coronary artery (LMCA) disease and identify the predictors of coronary events at one year in patients with LMCA stenoses. BACKGROUND: Significant (> or =50% diameter stenosis [DS]) LMCA disease has a poor long-term prognosis. METHODS: One hundred twenty-two patients who underwent angiographic and IVUS assessment of the severity of LMCA disease and who did not have subsequent catheter or surgical intervention were followed for one year. Standard clinical, angiographic and IVUS parameters were collected. RESULTS: The quantitative coronary angiography (QCA) reference diameter (3.91 +/- 0.76 mm, mean +/- 1 SD) correlated moderately with IVUS (4.25 +/- 0.78 mm, r = 0.492, p = 0.0001). The lesion site minimum lumen diameter (MLD) (2.26 +/- 0.82 mm) by QCA correlated less well with IVUS (2.8 +/- 0.82 mm, r = 0.364, p = 0.0005). The QCA DS measured 42 +/- 16%. During the follow-up period, 4 patients died, none had a myocardial infarction, 3 underwent catheter-based LMCA intervention and 11 underwent bypass surgery. Univariate predictors of events (p < 0.05) were diabetes, presence of another lesion whether treated with catheter-based intervention or untreated with DS > 50% and IVUS reference plaque burden and lesion lumen area, maximum lumen diameter, MLD, plaque area and area stenosis. Using logistic regression analysis diabetes mellitus, an untreated vessel (with a DS > 50%) and IVUS MLD were independent predictors of cardiac events. CONCLUSIONS: In selected patients assessed by IVUS, moderate LMCA disease had a one-year event rate of only 14%. Intravascular ultrasound MLD was the most important quantitative predictor of cardiac events. For any given MLD, the event rate was exaggerated in the presence of diabetes or another untreated lesion (>50% DS).