Impact of stent diameter on clinical outcomes following percutaneous coronary intervention with thirdgeneration drug-eluting stents: results from inspirion and latitude trials

INTRODUCTION: In patients treated with bare metal stents and earlygeneration drug-eluting stents (DES) smaller stent diameter (SD) has been associated with worse long-term outcomes after percutaneous coronary intervention (PCI). Data on the impact of small SD on outcomes after PCI with third generation DES is scarce. OBJECTIVE: The aim of this study was to evaluate the impact of SD on clinical outcomes, using a third generation sirolimus-eluting coronary stent with thin struts and abluminal biodegradable polymer. METHODS: Consecutive patients treated with Inspiron® (Scitech, Brazil) in native coronary arteries lesions between June 2017 and January 2022 were included, in a total of 25 Brazilian centers. Patients were grouped according to SD: 3.50mm. One-year event rates were estimated using the Kaplan-Meier method and adjusted hazard ratios were generated using Cox regression analysis. The primary endpoint was a composite of major adverse cardiovascular events (MACE) defined by the composite of cardiovascular death, myocardial infarction (MI) or target-lesion revascularization (TLR) at 12 months. RESULTS: Of the 2,803 patients who underwent PCI with Inspiron®, 24,5% (n = 688) had SD ≤2.50 mm, 45.0% (n = 1,263) had SD 2.75-3.00mm and 30,4% (n = 852) had SD >3.50 mm. At 1 year, MACE rates were 3.1%, 2.1% and 1.3%, respectively, with increasing SD (p = 0.054). Death due to CV causes at 12 months rates decreased with increasing SD (2.9%, 1.8% and 0.8%, respectively [p < 0.009]) whereas rates of MI related study device at 12 months across SD groups were comparable (0.0%, 0.5%, and 0.1%, respectively [p = 0.086]). After multivariate stepwise Cox regression, smaller SD remained associated with higher rates of MACE (HR 0.46, 95%CI of 0.241-0.890; p=0.022). As seen in Figure 1, the risk of MACE is significantly increased in the first 30 days and remain higher up to 12 months among individuals with mean vessel diameter <2.50mm. CONCLUSIONS: In a large cohort of patients undergoing PCI with third generation DES MACE rates were low, but still higher among patients with smaller SD, mainly drive by higher CV deaths at 12 months. Further research into the optimal treatment strategy of small coronary arteries is still warranted.

Implante de stents com ou sem pré-dilatação em pacientes com síndrome coronária aguda sem supradesnivelamento do segmento ST / Stent implantation with or without pre-dilatation in non-ST-segment-elevation acute coronary syndrome patients

INTRODUÇÃO: O benefício do implante direto de stent não está bem estabelecido na síndrome coronária aguda sem supradesnivelamento do segmento ST (SCASST). Comparamos aqui o implante de stent, com ou sem pré-dilatação (stent direto) da lesão-alvo nessa população. MÉTODOS: Registro unicêntrico, retrospectivo, que incluiu pacientes com SCASST tratados entre 2009 a 2010. Foram excluídas lesões reestenóticas, lesões em enxertos de safena ou em bifurcações. O desfecho primário foi a comparação de eventos cardíacos adversos maiores (ECAM) hospitalares e tardios. RESULTADOS: Do total de 182 pacientes avaliados, 42,3% foram tratados com stent direto. A idade da população foi de 61,1 ± 11,0 anos, sendo 67% do sexo masculino e 33,5% diabéticos. Os pacientes do grupo pré-dilatação apresentaram mais lesões do tipo C (37,1% vs. 18,2%; P <0,01), menor diâmetro de referência do vaso (2,3 [2,0-2,7] mm vs. 2,7 [2,2-3,1] mm; P <0,01) e menor diâmetro luminal mínimo pré-intervenção (0,5 [0,1-0,7] mm vs. 0,6 [0,4-1,0] mm; P < 0,01). Calcificação moderada/grave foi evidenciada em 13,2% dos casos, igualmente distribuídos entre os grupos. Não foram observadas diferenças na ocorrência de complicações angiográficas periprocedimento (3,9% vs. 4,8%; P > 0,99). As taxas de ECAM hospitalar não diferiram entre os grupos, embora os pacientes submetidos ao implante direto tenham apresentado metade dos eventos (2,6% vs. 5,7%; P = 0,47). Ao final de 1 ano, os ECAM foram semelhantes entre os grupos (6,5% vs. 5,7%; P > 0,99 ). CONCLUSÕES: Nesta série de pacientes com SCASST, o implante direto de stent não esteve associado a melhores resultados angiográficos ou clínicos. Contudo, a complexidade da lesão permanece como fator determinante na escolha da estratégia de pré-dilatação na prática diária.

BACKGROUND: The benefits of direct stenting in non-ST-segment-elevation acute coronary syndromes (NSTE ACS) are not clearly established. We compared stenting with or without pre-dilatation (direct stenting) of the target lesion in this population. METHODS: Single center, retrospective registry including NSTE ACS patients treated from 2009 to 2010. Stenting for bifurcations, saphenous vein grafts, and in-stent restenosis were excluded. The primary endpoint was the comparison of in-hospital and late major adverse cardiac events (MACE). RESULTS: Of a total of 182 patients, 42.3% were treated by direct stenting. Mean age was 61.1 ± 11.0 years, 67% were male and 33.5% were diabetics. Patients in the pre-dilatation group had more type C lesions (37.1% vs. 18.2%; P = 0.01), smaller reference vessel diameter (2.3 [2.0-2.7] mm vs. 2.7 [2.2-3.1] mm; P = 0.01) and smaller preintervention minimal luminal diameter (0.5 [0.1-0.7] mm vs. 0.6 [0.4-1.0] mm; P < 0.01). Moderate/severe calcification was observed in 13.2% of the cases, and was equally distributed in both groups. There were no differences in the occurrence of periprocedural angiographic complications (3.9% vs. 4.8%; P = 0.99). In-hospital MACE was not different between groups, although patients submitted to direct stenting have shown half of the events (2.6% vs. 5.7%; P = 0.47). At the end of 1 year, the MACE rate was similar for the two groups (6.5% vs. 5.7%; P > 0.99). CONCLUSIONS: In this series of NSTE ACS patients, direct stenting was not associated with better angiographic or clinical outcomes. However, lesion complexity remains a determinant factor in the choice of the pre-dilatation strategy in daily practice.

Paciente com sequestro pulmonar intralobar: uma rara anomalia congênita / Patient with intralobar pulmonary sequestration: a rare congenital anomaly

Paciente do sexo masculino, com 51 anos de idade, com história de pneumonias de repetição desde a segunda década de vida. As radiografias de tórax curiosamente demonstravam omesmo padrão radiológico com envolvimento do lobo inferioresquerdo. Foi realizada tomografia helicoidal de tórax, que revelouvaso arterial anômalo emergindo da aorta torácica descendente em direção ao lobo pulmonar inferior esquerdo,caracterizando sequestro pulmonar. Os achados foram confirmados por aortografia torácica, sendo o paciente encaminhado para tratamento cirúrgico.

A 51-year-old male patient had a history of recurrent pneumonia since the second decade of life. Interestingly enough, chest X-rays showed the same radiological pattern with involvement of the left lower lobe. A multislice spiral CT scan of the chest was performed and depicted an anomalous arterial vessel emerging from the descending thoracic aorta towards the left lower pulmonary lobe, characterizing pulmonary sequestration. The findings were confirmed by thoracic aortography, and the patient was referred for surgical treatment.

[Leber's miliary aneurysms associated with vitreomacular traction syndrome: case report]. / Aneurisma miliar de Leber associado à síndrome de tração vítreomacular: relato de caso.

Retinal telangiectasias are idiopathic vascular abnormalities of the retina characterized by irregular dilatation of the retinal vessels, intraretinal and subretinal exudation. The aim of this article is to describe the uncommon association of Leber's miliary aneurysms and vitreomacular traction syndrome in a female patient. The diagnosis was established with angiofluoresceinography and optic coherence tomography. The patient was treated with focal photocoagulation with argon green laser directed to the perimacular aneurysms and pars plana posterior vitrectomy. The visual acuity showed great improvement after a four-month follow-up. The present report supports the importance of optic coherence tomography in cases where the vitreoretinal interface must be evaluated, including vascular pathologies, which allowed us to offer a better treatment to this patient.

Aneurisma miliar de Leber associado à síndrome de tração vítreomacular: relato de caso / Leber's miliary aneurysms associated with vitreomacular traction syndrome: case report

Telangiectasias retinianas são anormalidades vasculares primárias e idiopáticas caracterizadas por dilatações irregulares e incompetência dos vasos retinianos com variados graus de exsudação intra e sub-retiniana. O objetivo desse relato é documentar uma rara associação entre aneurisma miliar de Leber e síndrome de tração vítreomacular bem caracterizada à angiofluoresceinografia e tomografia de coerência óptica. O tratamento realizado foi fotocoagulação com laser de argônio nos aneurismas perimaculares e cirurgia de vitrectomia posterior via pars plana, o que resultou em melhora consistente da acuidade visual. O caso relatado confirma a importância da tomografia de coerência óptica em estudar a interface vítreorretiniana e suas alterações, o que permitiu abordagem completa da doença em questão.

Retinal telangiectasias are idiopatic vascular abnormalities of the retina characterizad by irregular dilatation of the retinal vessels, intraretinal and subretinal exsudation. The aim of this article is to describe the uncommon association of Leber's miliary aneurysms and vitreomacular traction syndrome in a female patient. The diagnosis was established with angiofluoresceinography and optic coherence tomography. The patient was treated with focal photocoagulation with argon green laser directed to the perimacular aneurysms and pars plana posterior vitrectomy. The visual acuity showed great improvement after a four-month follow-up. The present report supports the importance of optic coherence tomography in cases where the vitreoretinal interface must be evaluated, including vascular pathologies, which allowed us to offer a better treatment to this patient.