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Impact of stent overlap on long-term clinical outcomes in patients treated with newer-generation drug-eluting stents

Selected in EuroIntervention by S. Brugaletta

References

Authors

O’Sullivan, C Stefanini, GG Räber, L Heg, D Taniwaki, M Kalesan, B Pilgrim, T Zanchin, T Moschovitis, A Büllesfeld, L Khattab, A Meier B, Wenaweser P, Jüni P, Windecker S

Reference

EuroIntervention. 2014 Jan 22;9(9):1076-84

Published

January 2014

Link

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Aims 

Early-generation drug-eluting stent (DES) overlap (OL) is associated with impaired long-term clinical outcomes whereas the impact of OL with newer-generation DES is unknown. Our aim was to assess the impact of OL on long-term clinical outcomes among patients treated with newer-generation DES.

Methods and results 

We analysed the three-year clinical outcomes of 3,133 patients included in a prospective DES registry according to stent type (sirolimus-eluting stents [SES; N=1,532] versus everolimus-eluting stents [EES; N=1,601]), and the presence or absence of OL. The primary outcome was a composite of death, myocardial infarction (MI), and target vessel revascularisation (TVR). The primary endpoint was more common in patients with OL (25.1%) than in those with multiple DES without OL (20.8%, adj HR=1.46, 95% CI: 1.03-2.09) and patients with a single DES (18.8%, adj HR=1.74, 95% CI: 1.34-2.25, p<0.001) at three years. A stratified analysis by stent type showed a higher risk of the primary outcome in SES with OL (28.7%) compared to other SES groups (without OL: 22.6%, p=0.04; single DES: 17.6%, p<0.001), but not between EES with OL (22.3%) and other EES groups (without OL: 18.5%, p=0.30; single DES: 20.4%, p=0.20).

Conclusions 

DES overlap is associated with impaired clinical outcomes during long-term follow-up. Compared with SES, EES provide similar clinical outcomes irrespective of DES overlap status.

My Comment

What is known

Stent overlap occurs in up to 30% of patients undergoing percutaneous coronary intervention (PCI) in contemporary clinical practice for a variety of reasons including excessive target lesion length, incomplete lesion coverage, edge dissections and residual thrombus. In the largest study to date addressing long-term clinical outcomes among patients treated with the unrestricted use of early-generation overlapping DES, patients with DES overlap had a higher incidence of major adverse cardiac events (MACE) (cardiac death, myocardial infarction, ischaemia-driven TLR) and impaired angiographic results as compared with non-overlapping or single DES control groups. As compared with early-generation devices, newer-generation DES, such as the everolimus-eluting stent (EES), have improved upon the safety and efficacy profile of early-generation devices. However, the impact of newer-generation DES on long-term clinical outcomes among patients with DES overlap is unknown. The authors sought herein to compare the long-term clinical outcomes among patients treated with newer (i.e., EES) and earlier-generation DES overlap (i.e., SES) with non-overlapping DES controls stratified according to stent type.

Major findings 

  • At three years, the primary outcome (composite of death, myocardial infarction and target vessel revascularisation) was more common in patients with overlap than in those with multiple DES without overlap (adjusted HR 1.46, 95% CI: 1.03 – 2.09) and patients with a single DES (adjusted HR 1.74, 95% CI: 1.34 – 2.25)
  • A stratified analysis by stent type showed a higher risk of primary outcome in SES with overlap compared to other SES groups, but not between EES with overlap and other EES group.

My comments

This paper describes a large cohort of patients with overlap DES, finding that DES overlap is associated with impaired clinical outcomes during long-term follow-up. Of note is that compared with SESs, EESs conversely provide similar clinical outcomes irrespective of DES overlap status. Given the fact that DES overlap is frequent in clinical practise (up to 30%), the findings of the present paper are of importance and represent another point in favour of new-generation drug-eluting stents, together with other data recently published on overlap. It would be interesting to know whether this new generation DES improvement in overlapping is also present in STEMI patients, where the thrombotic milieu can provoke higher rate of malapposed struts than stable plaques. 

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