Balancing the Risks of Restenosis and Stent Thrombosis in Bare-Metal Versus Drug-Eluting Stents

Garg, Pallav; Cohen, David J.; Gaziano, Thomas A.; Mauri, Laura

doi:10.1016/j.jacc.2008.01.042

Cited by 66 publications

(47 citation statements)

References 43 publications

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“…Garg and colleagues reported a small increase in DES thrombosis compared with BMS after one year (>0.14%/year). 8 This rate is, however, considerably lower than that reported by Daemen and Wenaweser and colleagues, who found that LST occurs in both DES at a steady rate of 0.5 % per year during follow-up up to four years, but in this report BMS were not included. 9,10 Their overall results suggest that LST was slightly, but significantly more frequent with PES than with SES (cumulative incidence at four years of 3.6 vs. 2.7% respectively, p=0.02), but this was mainly due to a Late stent thrombosis, endothelialisation and drug-eluting stents different outcome during the first year (2.0 vs. 1.3% respectively).…”

contrasting

confidence: 59%

Late stent thrombosis, endothelialisation and drug-eluting stents

Ertaş

Beusekom²,

Giessen³

2009

NHJL

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Drug-eluting stents (DES) significantly reduce the risk of restenosis after percutaneous coronary revascularisation, but an increased risk of late stent thrombosis (LST) has been put forward as a major safety concern. Meta-analysis of clinical trials, however, does not support this caveat. Even so, many interventional cardiologists think that LST is associated with DES and related to delayed endothelialisation. This hypothesis is based on autopsy studies and clinical intracoronary angioscopy. In autopsy studies, differences between endothelialisation of DES and baremetal stents (BMS) have been reported. Most preclinical studies, however, have failed to show any significant differences in endothelialisation between DES and BMS. Our own studies, using the porcine coronary artery model, also suggest that DES show no differences in re-endothelialisation. However, DES do delay vascular healing and induce endothelial dysfunction. This paper will review clinical and animal studies which consider re-endothelialisation and LST. (Neth Heart J 2009;17:177-81.)Keywords: drug-eluting stents, stent thrombosis, endothelium, endothelial function P olymer-based sirolimus (SES) and paclitaxel (PES) eluting coronary stents have reduced rates of restenosis and late lumen loss compared with bare-metal stents (BMS), resulting in a significant reduction in the need for target vessel revascularisation. 1,2 Delayed healing and more specifically delayed re-endothelialisation after drug-eluting stent (DES) implantation have been suggested as the cause of late stent thrombosis (LST, defined as thrombosis ≥30 days after stent deployment). 3 This concept is based on clinical autopsy studies and clinical intracoronary angioscopy studies. 4,5 However we feel this concept is still open to debate. Our hypothesis is that delayed re-endothelialisation alone is not adequate to explain LST. The pathogenesis of LST is still not completely understood, and may be affected by a combination of factors. The present review discusses possible pathophysiological mechanisms of stent thrombosis in DES. DES induced late stent thrombosis, clinical studiesRecent reports from randomised trials suggest that some DES may be associated with increased rates of LST as compared with BMS. Stone et al. reported that both SES and PES were associated with a significant increase in the incidence of LST between one and four years after implantation (0.6 and 0.7%), as compared with BMS (0.2%). 6 Stettler and colleagues suggested that there is no evidence of an overall increase in definite stent thrombosis associated with SES between one and four years (0.3 vs. 0.2% in BMS). 7 However, the risk of LST seemed to be increased with PES (0.6%) with a significantly increased hazard ratio (2.1, p=0.017 vs. BMS between day 0 and 4 years). Garg and colleagues reported a small increase in DES thrombosis compared with BMS after one year (>0.14%/year). 8 This rate is, however, considerably lower than that reported by Daemen and Wenaweser and colleagues, who found that LST occurs in both D...

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contrasting

confidence: 59%

Late stent thrombosis, endothelialisation and drug-eluting stents

Ertaş

Beusekom²,

Giessen³

2009

NHJL

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“…23 Because there are no published data on the utility decrement associated with LAA occlusion, we assumed this to be the same as that associated with a percutaneous coronary revascularization procedure. 38 Additional utility decrements were applied if a procedure-related complication (eg, stroke) occurred.…”

Section: Quality-of-life Estimatesmentioning

confidence: 99%

Economic Evaluation of Percutaneous Left Atrial Appendage Occlusion, Dabigatran, and Warfarin for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation

2013

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Background-Percutaneous left atrial appendage (LAA) occlusion and novel pharmacological therapies are now available to manage stroke risk in patients with nonvalvular atrial fibrillation; however, the cost-effectiveness of LAA occlusion compared with dabigatran and warfarin in patients with nonvalvular atrial fibrillation is unknown. Methods and Results-Cost-utility analysis using a patient-level Markov microsimulation decision analytic model with a lifetime horizon was undertaken to determine the lifetime costs, quality-adjusted life years, and incremental costeffectiveness ratio of LAA occlusion in relation to dabigatran and warfarin in patients with nonvalvular atrial fibrillation at risk for stroke without contraindications to oral anticoagulation. The analysis was performed from the perspective of the Ontario Ministry of Health and Long Term Care, the third-party payer for insured health services in Ontario, Canada. Effectiveness and utility data were obtained from the published literature. Cost data were obtained from the Ontario Drug Benefits Formulary and the Ontario Case Costing Initiative. Warfarin therapy had the lowest discounted quality-adjusted life years at 4.55, followed by dabigatran at 4.64 and LAA occlusion at 4.68. The average discounted lifetime cost was $21 429 for a patient taking warfarin, $25 760 for a patient taking dabigatran, and $27 003 for LAA occlusion. Compared with warfarin, the incremental cost-effectiveness ratio for LAA occlusion was $41 565. Dabigatran was extendedly dominated. Conclusions-Percutaneous

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“…This is in agreement with a study showing that patients who benefit most from DES in terms of net clinical outcome are those at higher risk of restenosis, including patients with diabetes. 22 Of note, DM patients with bifurcation lesions had worse long-term outcomes than patients without, regardless of stent type, consistently with other PCI settings. 23,24 In fact, DM is characterized by a variety of mechanisms responsible for accelerated atherosclerosis affecting the entire coronary circulation, 25,26 and DES does not address nontarget lesions related to disease progression and plaque rupture.…”

Section: Capodanno Et Al Bifurcations In Patients With Diabetes Mellitusmentioning

confidence: 66%

Impact of Drug-Eluting Stents and Diabetes Mellitus in Patients With Coronary Bifurcation Lesions: A Survey From the Italian Society of Invasive Cardiology

Capodanno¹,

Tamburino²,

Sangiorgi³

et al. 2011

Circ: Cardiovascular Interventions

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Balancing the Risks of Restenosis and Stent Thrombosis in Bare-Metal Versus Drug-Eluting Stents

Cited by 66 publications

References 43 publications

Late stent thrombosis, endothelialisation and drug-eluting stents

Late stent thrombosis, endothelialisation and drug-eluting stents

Economic Evaluation of Percutaneous Left Atrial Appendage Occlusion, Dabigatran, and Warfarin for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation

Impact of Drug-Eluting Stents and Diabetes Mellitus in Patients With Coronary Bifurcation Lesions: A Survey From the Italian Society of Invasive Cardiology

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