Influence of lesion length on restenosis after coronary stent placement

doi:10.1016/S0002-9149(99)00165-4

The American Journal of Cardiology

Volume 83, Issue 12, 15 June 1999, Pages 1617-1622

https://doi.org/10.1016/S0002-9149(99)00165-4 Get rights and content

Abstract

The length of a coronary lesion is a significant predictor of restenosis after balloon angioplasty. The influence of lesion length has not comprehensively been assessed after coronary stent placement. This study includes 2,736 consecutive patients with coronary stent placement. Only patients with recent or chronic occlusions before the intervention were excluded. Patients were divided in 2 groups: 573 patients with long lesions (≥15 mm) and 2,163 patients with short lesions (<15 mm). There were no significant differences between the groups with respect to the procedural success rate and incidence of subacute thrombosis. One-year event-free survival was lower in patients with long lesions (73.3% vs 80.0%, p = 0.001). Six-month angiography was performed in 82.5% of the eligible patients. The incidence of binary restenosis (≥50% diameter stenosis) was higher in patients with long lesions (36.9% vs 27.9%, p <0.001). Similarly, patients with long lesions presented more late lumen loss than those with short lesions (1.29 ± 0.89 vs 1.07 ± 0.77 mm, p <0.001). Multivariate models for both binary restenosis and late lumen loss demonstrated that lesion length was an independent risk factor for restenosis. The risk was further increased by multiple stent placement and overlapping stents that were also independent risk factors of restenosis. Stented segment length did not show any independent effect. Therefore, long lesions represent an independent risk factor for restenosis after coronary stent placement. The results of this study suggest that a possible way to reduce the risk is to cover the lesion with a minimal number of nonoverlapping stents.

Section snippets

Patients

This study includes a consecutive series of patients with symptomatic coronary artery disease who underwent coronary stent placement from January 1994 to October 1997. Exclusion criteria were only recent and chronic occlusions that precluded the assessment of lesion length.

Stent placement and poststenting treatment

The stent placement and poststenting therapy has been described previously.15, 16 Various stent types were implanted, including Palmaz-Schatz (Johnson & Johnson Interventional Systems Co., Warren, New Jersey), Inflow (Inflow

Clinical outcome

The study population comprised 2,736 patients. Using the cut-off value of 15 mm, 573 patients (21%) had long lesions and 2,163 patients had short lesions. The proportion of patients with long lesions remained relatively stable over the years of the study period: 17% in the first, 23% in the second, and 21% both in the third and fourth year (p = 0.20). Main baseline characteristics of the patients are listed in Table Iand compared between patients with long lesions and patients with short

Discussion

The main finding of this study is that long lesions are associated with a less favorable long-term clinical and angiographic outcome than shorter lesions, but without a significant influence on procedural success rate and incidence of subacute thrombosis. Greater lesion length exercises an independent negative effect that is further potentiated by placing multiple and overlapping stents.

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Cited by (201)

Immediate, medium- and long-term outcomes of percutaneous coronary intervention with very long drug eluting stent : An observational multicentric study
2023, Annales de Cardiologie et d'Angeiologie
Les lésions coronaires très longues représentent 20 % des sténoses coronariennes dans la pratique quotidienne. Il existe peu de données concernant l'efficacité des angioplasties de ces lésions avec stents actifs (SA) très longs, dans la littérature. Nous avons mené cette étude afin d’évaluer les résultats au long cours des angioplasties avec SA de longueur ≥ 40 mm dans une population cumulant plusieurs facteurs de risque cardiovasculaires.
Il s'agit d'une étude rétrospective, multicentrique, descriptive et pronostique, menée entre janvier 2015 et janvier 2020, dans quatre centres Tunisiens, incluant tous les patients ayant bénéficié d'une angioplastie avec un SA de longueur ≥ 40 mm. Le critère de jugement primaire était l'incidence d’évènement cardiovasculaires majeurs (ECVM) (accident vasculaire cérébral, syndrome coronarien aigu, revascularisation de la lésion cible : TLR et décès cardiovasculaire : DCV).
Nous avons inclus 480 procédures. Plus de la moitié des patients cumulaient au moins trois facteurs de risque. La prévalence de l'hypertension artérielle, de diabète et de tabagisme était respectivement de 61,1 %, 56,6 % et 60,4 %. Les lésions traitées étaient complexes : lésions calcifiées dans 23,54 % des cas, occlusions chroniques dans 8,75 %, lésions de bifurcations dans 25 % des cas et des lésions ostiales dans 12,08 % des cas. La longueur moyenne des stents était de 47,72 mm. Nous avons relevé 17 cas de complications per-procédurales (3,55 %). La médiane de suivi était de 31,5 mois (extrêmes 1–60 mois). Le taux de thrombose de stent était de 0,83 %. L'incidence des ECVM, de TLR et de DCV étaient respectivement de 16,25 %, 8,12 % et 5,2 %. En analyse multivariée, le diabète (HR = 1,7, IC 95 % [1,01–2,9], la dyslipidémie (HR = 2,08, IC 95 % [1,3–3,3]), la coronaropathie familiale (HR = 1,9, IC 95 % [1,01–3,6]), la dysfonction du ventricule gauche (HR = 2,07, IC 95 % [1,1–3,6]) et les lésions de bifurcations (HR = 1,9 (IC 95 % [1,2–3,14]) étaient les facteurs prédictifs indépendants d'ECVM, alors que la prise de statines (HR = 0,38, IC 95 % [0,19–0,78]) était un facteur protecteur.
L'angioplastie avec SA très long est associée à un taux acceptable d'ECVM, de TLR, de thrombose de stent et de DCV dans notre population malgré le haut risque ischémique. Elle représente ainsi une alternative séduisante de la chirurgie cardiaque. Des études randomisées comparatives des deux stratégies thérapeutiques s'imposent.
Very long coronary lesions account for 20% of coronary stenoses in the real world. There are few data on the effectiveness of angioplasty of these lesions with very long active stents (DES) in the literature. We conducted this study to assess the long-term outcomes of angioplasty with DES length ≥ 40 mm in a population with multiple cardiovascular risk factors.
This is a retrospective, multicenter, descriptive, and prognostic study, conducted between January 2015 and January 2020, in four Tunisian centers, including all patients who underwent angioplasty with a DES of length ≥ 40 mm with a follow-up of at least one year. The primary outcome was a combined criteria (major cardiovascular and Cerebral events: MACCE) (stroke, acute coronary syndrome, revascularization of the target lesion: TLR, cardiovascular death: CVD).
We included 480 procedures. More than half of the patients had at least three risk factors. The prevalence of high blood pressure, diabetes and smoking were 61.1%, 56.6% and 60.4%, respectively. The treated lesions were complex: 23.54% calcified lesions, 8.75% chronic occlusions, 25% bifurcation lesions and 12.08% ostial lesions. The average length of the stents was 47.72 mm. We noted 17 cases of per-procedural complications (3.55%). The median follow-up was 35 months (extremes 1–60 months). The rate of stent thrombosis was 0.83%. The incidence of MACCE, TLR and CVD were respectively 16.25%, 8.12% and 5.2%. In multivariate analysis, diabetes (HR = 1.7, 95% CI [1.01–2.9]), dyslipidemia (HR = 2.08, 95% CI [1.3–3.3]), familial coronary artery disease (HR = 1.9, 95% CI [1.01–3.6]), left ventricle dysfunction (HR = 2.07, 95% CI [1.1–3.6]) and bifurcation lesions (HR = 1.9, 95% CI [1.2–3.14]) were the independent predictors of MACCE, while statin intake (HR = 0.38, 95% CI [0.19–0.78]) was a protective factor.
Angioplasty with very long DES is associated with low levels of MACCE, TLR, stent thrombosis and CVD in our population. Therefore, it could be an interesting alternative to cardiac surgery. Randomized comparative studies of the two treatment options are needed.
Outcomes of the Novel Supreme Drug-Eluting Stent in Complex Coronary Lesions: A PIONEER III Substudy
2022, Journal of the Society for Cardiovascular Angiography and Interventions
The Supreme healing-targeted drug-eluting stent (DES) is designed to promote endothelial healing to reduce stent-related adverse events. This may be particularly relevant among complex lesions that have a higher rate of adverse events. We sought to compare 1-year outcomes of percutaneous coronary intervention in complex lesions between the Supreme DES and contemporary durable-polymer, everolimus-eluting stents (DP-EES).
PIONEER III was a multicenter, prospective, single-blind clinical trial, randomizing 1629 patients with either an acute or chronic coronary syndrome in a 2:1 ratio to the Supreme DES or DP-EES. Complex lesions (American College of Cardiology/American Heart Association type B2/C) were found in 1137 patients. Outcomes were also compared for specific parameters of lesion complexity: severe calcification, long length (>20 mm), and severe tortuosity. The primary end point was target lesion failure at 1 year.
At 1 year, there was no difference in target lesion failure between the Supreme DES and DP-EES: (5.7% vs 5.6%; hazard ratio 1.00, 95% confidence interval 0.59-1.68, P = .99). Similarly, there were no differences in the secondary end points of lesion success (99.7% vs 99.4%, P = .41), device success (97.0% vs 98.5%, P = .14), target vessel failure (6.5% vs 7.4%, P = .50), major adverse cardiac events (7.8% vs 8.5%, P = .64), or stent thrombosis (0.7% vs 1.1%, P = .48). A trend was observed toward a higher rate of target lesion revascularization with the Supreme DES (2.5% vs 0.9%, P = .06).
This study suggests that the Supreme DES is as effective and safe at 1 year compared with the standard DP-EES across a broad spectrum of lesion complexity.
Long-term clinical outcomes after percutaneous coronary intervention to treat long lesions in hemodialysis patients in the era of second-generation drug-eluting stents
2020, Journal of Cardiology
There is little knowledge about clinical outcomes after the percutaneous coronary intervention (PCI) in hemodialysis patients with long lesions. The objective of the present study was to examine the long-term prognosis after PCI in hemodialysis patients in the second-generation drug-eluting stents (DES) era.
We retrospectively enrolled 270 consecutive hemodialysis patients who underwent PCI using second-generation DES from January 2010 to July 2015. We defined long lesions as the total stent length >30 mm. In total, 96 hemodialysis patients (35.6%) underwent PCI for long lesions. The median follow-up period was 2.7 years. The endpoints of this study were cardiac death, target lesion revascularization (TLR), and major adverse cardiovascular events (MACE), including cardiac death, non-fatal myocardial infarction, non-fatal stroke, stent thrombosis, and TLR.
The patients’ baseline characteristics were similar between the long lesion and the non-long lesion groups, except for prior PCIs (long-lesion vs. non-long lesion = 30.2% vs. 46.0%; p = 0.01). Kaplan–Meier analyses revealed that the incidence of cardiac death, TLR, and MACE were comparable between the two groups (long lesion vs. non-long lesion; 5.2% vs. 5.7%, log-rank p = 0.84, 26.0% vs. 23.0%, log-rank p = 0.29, and 43.8% vs. 40.2%; log-rank p = 0.49, respectively).
Clinical outcomes of PCI for long lesions in hemodialysis patients were similar to that of non-long lesions. Long-stenting in hemodialysis patients, who were considered high-risk subset of adverse cardiovascular events, might be acceptable in the second-generation DES era.
Orbital Atherectomy for the Treatment of Long (≥25–40 mm) Severely Calcified Coronary Lesions: ORBIT II Sub-Analysis
2020, Cardiovascular Revascularization Medicine
Citation Excerpt :
In this study, we sought to perform a subgroup analysis of the ORBIT II trial with specific focus on longer (≥25–40 mm) lesions, as there is currently limited published data regarding use of OA in this subgroup. PCI of longer target lesions is known to be associated with worse clinical outcomes, likely due to extensive manipulation and injury to the arterial luminal wall causing exaggerated neointimal hyperplasia [8–10]. Operators may thus be understandably cautious in approaching these longer lesions with OA due to the potential for longer treatment time and the possible increase in embolic material.
Orbital atherectomy (OA) is an effective method of lesion preparation of severely calcified vessels prior to stent deployment. Long calcified lesions may lead to higher risk of post-procedural complications, yet the optimal treatment strategy has not been established. In this study we sought to determine the safety and efficacy of OA in patients with long (≥25–40 mm) calcified target lesions.
ORBIT II was a single-arm trial that enrolled 443 patients at 49 U.S. sites. De novo, severely calcified coronary lesions were treated with OA prior to stenting. Patients treated with the OA device were stratified into two groups according to target lesion length as visually estimated by the investigator: those with short (<25 mm; N = 314) vs. long (≥25–40 mm; N = 118) lesions. Lesions >40 mm were excluded per protocol. The primary endpoint was the 3-year major adverse cardiac event (MACE) rate, defined as a composite of cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR).
The 3-year MACE rates in patients with short (<25 mm) vs. long (≥25–40 mm) lesions were 21.1% vs. 29.9% respectively (p = 0.055). The rate of cardiac death (6.5% vs. 7.8%, p = 0.592) and TVR (8.5% vs. 13.7%, p = 0.153) did not significantly differ. The rate of MI (CK-MB > 3× ULN) at 3 years was significantly higher in patients with long (≥25–40 mm) lesions (9.0% vs. 17.0%, p = 0.024), with the majority occurring in-hospital (7.0% vs. 13.6%, p = 0.037).
Patients with long (≥25–40 mm) calcified target lesions had similar outcomes in terms of MACE at 3 years despite higher rates of MI, which mostly occurred in-hospital. Using the more contemporary SCAI definition of MI, there was no significant difference in rates of MI between the short (<25 mm) and long (≥25–40 mm) groups. Further studies are warranted to determine how OA compares to focal force balloon angioplasty, rotational atherectomy and other novel treatment options for long severely calcified lesions.
Percutaneous coronary intervention of long calcified lesions is inherently more complex and higher risk and may require more intensive lesion preparation. This sub-analysis of ORBIT II revealed that orbital atherectomy treatment of longer (≥25–40 mm) lesions was associated with a higher rate of MACE at 30 days, but not at 3 years. This difference, however, was driven primarily by a higher in-hospital non-Q-wave MI rate; using the more contemporary SCAI definition of MI, there was no significant difference in rates of MI between the short (<25 mm) and long (≥25–40 mm) groups.
Impact of everolimus-eluting stent length on long-term clinical outcomes of percutaneous coronary intervention
2018, Journal of Cardiology
Even though longer stented lengths may increase the risk of restenosis, full coverage of diffuse long lesions with longer stents seems to be the optimal strategy for percutaneous coronary intervention (PCI) in the new drug-eluting stent (DES) era. However, it remains unclear whether this strategy will indicate favorable outcome or not. This study evaluated the impact of stent length on two-year clinical outcomes after PCI with the XIENCE Alpine everolimus-eluting stent.
This was a retrospective, non-randomized, observational study. Four patient groups were classified according to implanted overall total stent length (short, <15 mm; middle, 15–23 mm; long, 24–32 mm; and ultra-long, >32 mm). The primary outcome of this study was major adverse cardiac events (MACE), defined as the composite of cardiac death, recurrent myocardial infarction (MI), target vessel revascularization (TVR), and stent thrombosis (ST). Angiographic restenosis by quantitative coronary angiography was defined as >50% diameter stenosis at 10 months after PCI.
A total of 730 patients who received intravascular ultrasound (IVUS)-guided PCI were enrolled. The short, middle, long, and ultra-long stent groups included 138 patients (149 lesions), 210 patients (235 lesions), 190 patients (209 lesions), and 192 patients (208 lesions), respectively. The primary outcome at two years did not differ among the four groups (MACE: 4.4% in short, 3.3% in middle, 4.7% in long, and 4.7% in ultra-long groups, p = 0.402); TVR, ST, MI, and cardiac mortality also did not differ among groups.
Long stenting using the XIENCE stent which was guided by IVUS for diffuse, long lesions was associated with favorable clinical outcomes at two years in daily clinical practice.
Evaluation and efficacy of long length Pronova XR Bioabsorbable Polymer stent in the treatment of long coronary lesions
2017, Indian Heart Journal
The study aims an observational registry of the long and extra-long length (>33 mm) Pronova XR stents in patients with long coronary lesions (>30 mm) in a prospective real world study.
Current study was conducted at Ruby Hall Clinic Pune, between July 2012 and July 2013 including 30 patients who underwent PTCA using long and extra-long Pronova XR stents. Among the stents used, one stent - 33 mm, 2 stents - 38 mm, 5 stents - 43 mm and 25 stents were of 48 mm in length. In particular average stent length for the study was 46.03 mm and the average stent diameter was 3.09 ± 0.41 mm.
For this study coronary angioplasty was performed using femoral approach and standard practice. Lesions were predilated using undersized balloons and study stent was deployed at pressure 7–26 atm. (12.8 ± 3.2 atm.) The successful delivery of stent at the intended lesion with visual residual stenosis less than 50% was defined as Procedural success. Follow up studies were conducted for all the patients at 30 days, 3 months and 6 months intervals. The predefined QCA parameters were calculated using Sanders Data System QCA plus software (Palo Alto, CA, USA).
No procedural complication was observed during the whole study. 100% successful stent placement was achieved in all patients. Six months clinical follow-up was available for all patients. No adverse events (Acute closure, angina, REPCI, MI, death, sub acute stent thrombosis) or hospitalization was reported for any of the patients except one. The Quantative Coronary Core Lab analysis post 6 months showed well-flowing stent with average late lumen loss 0.10 mm ±0.26.
In patients with long coronary lesions and very long length stent implantation series, Pronova XR showed excellent in 6 months results. This is for the first time reported that use of long length Pronova XR stents has shown so low restenosis rate and absent of mortality in six month period. These results offer a new opportunity to single long length stenting.

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Coronary Artery DiseaseInfluence of lesion length on restenosis after coronary stent placement

Abstract

Section snippets

Patients

Stent placement and poststenting treatment

Clinical outcome

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Eur Heart J

Luminal narrowing after percutaneous transluminal coronary angioplasty. A study of clinical, procedural, and lesional factors related to long-term angiographic outcome

Circulation

A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease

N Engl J Med

A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease

N Engl J Med

Long-term angiographic and clinical outcome of patients undergoing multivessel coronary stenting

Circulation

Coronary Artery Disease
Influence of lesion length on restenosis after coronary stent placement