Paclitaxel‐eluting stents for the treatment of chronic total coronary occlusions: A strategy of extensive lesion coverage with drug‐eluting stents

Abstract

The recanalization of a chronic total coronary occlusion (CTO) is hampered by a high rate of lesion recurrence. The goal of the present study is to assess the effect of paclitaxel-eluting stents in CTOs in a strategy of extensive stent coverage and the optional use of additional bare metal stents (BMSs). In 82 consecutive patients, a CTO (duration > 2 weeks) was successfully recanalized with implantation of one or more Taxus stents. These patients underwent a repeat angiography after 5.0 +/- 1.5 months and were assessed by quantitative angiography. The patients were compared with 82 clinically and lesion-matched patients from a consecutive series of 148 patients with CTOs treated by BMS in the preceding time period. In 21 of the 82 patients, additional lesions in the target artery not directly related to the original occlusion site were treated with BMSs (hybrid approach). The history of diabetes, extent of coronary artery disease, clinical symptoms, and angiographic features were similar in the Taxus and BMS group. Periprocedural adverse events were 3.3% with Taxus and 3.3% with BMS, but 12 months MACE was significantly lower in the group with exclusive use of Taxus (13.3% vs. 56.7%; P < 0.001), mainly due to a lower target lesion revascularization of 10.0% as compared to 53.4% (P < 0.001). There was only one late reocclusion with Taxus (1.7%) as compared to 21.7% with BMS (P < 0.05). However, in the hybrid group, the MACE rate was considerably higher, with 33.3%. Our data of a 80% reduction of target vessel failure as compared to BMS, with a lower risk of late reocclusions without increased acute adverse events, demonstrate the benefit of paclitaxel-eluting stents in CTOs. However, diffuse atherosclerosis in CTOs should be covered completely by the drug-eluting stents.

Use of drug‐eluting stents for chronic total occlusions: A systematic review and meta‐analysis

“…Target vessel reocclusion was significantly less frequent with DES vs. BMS in two [19,21] of five studies [6,18,19,21,22] that reported this outcome (odds ratio: 0.29, 95% CI: 0.14, 0.58, P for heterogeneity ¼ 0.16, I 2 ¼ 38%, Fig. 3B).…”

“…Follow-up angiographic outcomes were reported in 12 studies, including five uncontrolled case series [10,11,13,15,16], five comparative nonrandomized studies [18,19,21,22,27] and in both prospective, randomized controlled trials [6,25] (Table II). The study by Hoye provided angiographic outcomes only for the DES group [27].…”

“…The study by Hoye provided angiographic outcomes only for the DES group [27]. Follow-up angiography was done at 6 months [6,10,11,13,15,16,18,19,21,22,25,27], or 12 months [19]. In all studies binary in-segment angiographic restenosis was lower with DES implantation compared to BMS (odds ratio: 0.15, 95% CI: 0.08, 0.26, P for heterogeneity ¼ 0.20, I…”

“…In instances where multiple analyses of CTO outcomes were reported from a single center (RapamycinEluting Stent Evaluated at Rotterdam Cardiology Hospital registry (RESEARCH) registry [20,[27][28][29], Ospedale S. Camillo Forlanini, Rome, Italy [23,30,31] and Friedrich-Schiller University Jena in Jena, Germany [21,32]), only one study from each center, describing the largest patient cohort and/or longest duration of follow-up was selected. SES or PES was utilized in all retrieved studies; no trials reporting outcomes after everolimus-eluting or zotarolimus-eluting stent implantation in CTOs were found.…”

Percutaneous Treatment of Coronary Chronic Total Occlusions Part 1: Rationale and Outcomes

“…Therefore, DES treatment of the entire segment exposed to pre-dilatation angioplasty may yield greater reductions in restenosis and subsequent TLR than with balloon angioplasty alone or in combination with bare metal stents. 83,87 Nevertheless, percutaneous revascularisation of CTOs is routinely associated with more extensive stent placement. As a consequence, it is unclear whether the improvement in restenosis is offset by a potentially higher risk of thrombotic occlusion, by complications associated with stent fracture or by acquired late malapposition.…”