Early-generation versus new-generation drug-eluting stents in isolated chronic total occlusion: on the road to extinction?

BACKGROUND: The performance of second-generation drug-eluting stent (DES) versus first-generation DES implantation in patients with stable angina and single chronic total occlusion (CTO) has not yet been studied. Herein, we sought to investigate whether a successful percutaneous coronary intervention (PCI) for CTO using second-generation versus first-generation polymer-coated DES improved outcomes in a setting of isolated CTO. METHODS: Among 7765 patients undergoing elective PCIs between 2006 and 2011, a total of 742 single CTOs were identified. Of these, 496 had a successful PCI and 193 were implanted with DESs. The major adverse cardiovascular event (MACE) records were extracted from the national administrative database and all patients were linked to the 2-year follow-up. RESULTS: When compared to first-generation DES implantation, second-generation implantation once significantly reduced risk of MACE, both at 1-year (hazard ratio [HR], 0.15; 95% confidence interval [CI], 0.06-0.36; P=.01) and 2-year follow-up (HR, 0.27; 95% CI, 0.13-0.56; P=.01). The symptom-driven target lesion revascularization (TLR) also occurred less frequently in patients with second-generation DES vs first-generation DES within 2 years of follow-up (HR, 0.15; 95% CI, 0.05-0.44; P=.03). The substantial 2-year benefit of second-generation DES over first-generation DES also persisted after incorporating a propensity score analysis for MACE (HR, 0.24; 95% CI, 0.08-0.72; P=.01) and TLR (HR, 0.15; 95% CI, 0.05-0.49; P=.04). CONCLUSIONS: Successful PCI for CTO using thin-strut polymer-coated DES vs early-generation DES implantation improves outcomes after recanalization of isolated CTO in a setting of stable angina.

Successful recanalisation of isolated chronic total occlusions improves outcomes in long-term observation: a case-control study.

BACKGROUND AND AIM: The long-term benefit of percutaneous recanalisation of chronic total occlusion (CTO) is still unclear. Given advances in interventional cardiology over the last two decades, we sought to investigate whether a successful percutaneous coronary intervention for CTO (PCI-CTO) improves outcomes in an age- and gender-matched single-centre cohort of stable angina patients. METHODS: Out of 401 consecutive patients enrolled to the CTO-Registry database, 276 patients were included in the final analysis. Patients with unsuccessful PCI-CTO (n = 138) were age- and gender-matched in a 1:1 ratio with patients who underwent a successful procedure. The primary end-points included hard end-points comprising death and nonfatal myocardial infarction (MI) and a composite safety outcome measure of death, nonfatal MI and ischaemia-driven revascularisation. The secondary end-point was improvement in angina status or complete resolution of angina symptoms. Patients were followed up for six months and at two years. RESULTS: Patients who underwent a successful recanalisation of CTO, compared to those who underwent an unsuccessful procedure, revealed similar rates of composite death and MI at six months (0.7% vs. 1.4%; hazard ratio [HR], 0.50; 95% confidence interval ratio [CI], 0.05-4.80; p = 0.56) and two years (1.4% vs. 5.8%; HR 0.24; 95% CI 0.07-0.85; p = 0.053). A significant difference in composite safety end-points between subsets, although not recorded after six months of observation (8.7% vs. 15.2%; HR 0.54; 95% CI 0.27-1.07; p = 0.095), was noted at two years follow-up (15.2% vs. 29.7%; HR 0.47; 95% CI 0.29-0.77; p = 0.004). A greater improvement in symptom burden or resolution of angina symptoms was documented after a successful PCI at both six months (68.1% vs. 23.2%, p < 0.001; 80.4% vs. 34.8%, p < 0.001, respectively) and two years (52.2% and 8.0%, p < 0.001; 68.1% vs. 22.5%, p < 0.001, respectively). CONCLUSIONS: Successful recanalisation of CTO improves outcomes in long-term observation.

Major adverse cardiovascular events after drug-eluting stent implantation in patients with single chronic total occlusion: a single-center registry.

BACKGROUND: There are limited data on the long-term safety and efficacy of drug-eluting stents (DES) implantation in patients with stable angina referred for elective percutaneous coronary intervention (PCI) of chronic total occlusion (CTO). We therefore aim to investigate whether DES compared with bare-metal stent (BMS) implantation improves long-term outcomes after successful recanalization of single CTO. METHODS: A total of 345 consecutive patients who underwent successful recanalization of single CTO and received DES or BMS in the Cardioangiology Laboratories of the Medical University of Gdansk between January 1, 2006 and December 31, 2010 were included in the CTO Registry database. We compared the 1-year and long-term clinical outcomes of 137 consecutive patients who underwent PCI for CTO and DES implantation with outcomes of 208 patients after successful CTO treatment with BMS implantation. The median follow-up was 22.6 ± 3 months (21.0 ± 3.9 months for DES vs 23.6 ± 1.5 months for BMS; P<.001). The primary endpoints included a composite of all-cause death and non-fatal myocardial infarction (MI) and composite safety endpoint of major adverse cardiovascular events (MACEs), including death, MI and symptom-driven target lesion revascularization (TLR). A secondary endpoint was a symptom-driven TLR. RESULTS: After stent implantation we noted lower rates of the composite endpoint at 1-year (9.5% DES vs 18.3% BMS; P=.01) and long-term follow-up (11.7% DES vs 21.1% BMS; P=.02) due to fewer episodes of TLR in the DES group (5.1% DES vs 14.4% BMS; P=.006 at 1-year follow-up; 7.3% DES vs 14.4% BMS; P=.04 at long-term follow-up). No significant differences were documented in the rate of death, MI, or in-stent thrombosis between investigated subsets. After adjusting for patient and procedural characteristics as well as propensity, BMS implantation remained independently associated with an increased hazard of 1-year MACE (adjusted hazard ratio [AHR], 2.09; 95% confidence interval [CI], 1.2-3.64; P=.005) and long-term MACEs (AHR, 1.99; 95% CI, 1.18-3.38; P<.01). CONCLUSIONS: DES implantation during PCI for single CTO reduces MACE rate at 1-year and long-term follow-up due to the significant reduction of TLR in the DES group. Therefore, DES implantation should be preferred as an optimal treatment strategy of single CTO in stable angina patients.