Percutaneous Coronary Interventions for the Treatment of Stenoses in Small Coronary Arteries

Siontis, George C.M.; Piccolo, Raffaele; Praz, Fabien; Valgimigli, Marco; Räber, Lorenz; Mavridis, Dimitris; Jüni, Peter; Windecker, Stephan

doi:10.1016/j.jcin.2016.03.025

Cited by 70 publications

(61 citation statements)

References 52 publications

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“…Recently, the BELLO (Balloon Elution and Late Loss Optimization) randomized trial demonstrated that the treatment of small‐vessel disease with a paclitaxel DCB was associated with less angiographic late loss and similar rates of restenosis and revascularization when compared to “first‐generation” paclitaxel‐eluting stents (PES) at 6‐months and a lower incidence of major adverse cardiac event (MACE) at 3‐year follow‐up . The use of “second‐generation” everolimus‐eluting stent (EES) versus PES has demonstrated lower revascularization rates and better survival rates in high‐risk patients with small coronary artery disease ; furthermore, a recent meta‐analysis showed second‐generation DES (sirolimus eluting stent) to provide superior angiographic and clinical outcome than DCB for the treatment of small coronary vessels . However, there are currently no available data comparing outcomes in patients treated with paclitaxel‐DCB versus EES implantation in this lesion subset.…”

Section: Introductionmentioning

confidence: 99%

A propensity score matched comparative study between paclitaxel‐coated balloon and everolimus‐eluting stents for the treatment of small coronary vessels

Giannini

Latib

Ancona

et al. 2017

Cathet Cardio Intervent

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Section: Introductionmentioning

confidence: 99%

A propensity score matched comparative study between paclitaxel‐coated balloon and everolimus‐eluting stents for the treatment of small coronary vessels

Giannini

Latib

Ancona

et al. 2017

Cathet Cardio Intervent

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“…Of the 19 assessing the value of new-generation DES in small vessels. The investigators suggest that the benefit may be greater with novel-generation DES, but data in this regard could not be obtained.In closing, this study provides robust evidence demonstrating the superiority of first-generation SES compared with other classic coronary interventions in patients with small vessels(6). However, from a practical standpoint, the optimal strategy for the current treatment of these lesions cannot be inferred from the present study, as new-generation DES were not included and first-generation SES and PES are no…”

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confidence: 73%

Optimal Coronary Interventions in Small Vessels

Alfonso

García-Guimarães

2016

JACC: Cardiovascular Interventions

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C oronary interventions on small vessels, representing up to 30% to 40% of procedures, are challenging and often disappointing because of suboptimal acute results and high restenosis rates (1,2). In this setting, bare-metal stents (BMS) proved to be superior to balloon angioplasty (BA), with the greatest benefit encountered in patients with smaller vessels and suboptimal BA results (1,2). Because late luminal loss resulting from neointimal proliferation is relatively independent of vessel size, late angiographic findings after BMS implantation are poorer in small vessels (1,2). Drug-eluting stents (DES) drastically inhibit neointimal proliferation and are especially attractive in these patients. However, even with the advent of new-generation DES, small vessel disease remains a powerful predictor of restenosis (3). More recently, drug-coated balloons (DCB) have been incorporated into our armamentarium for lesions in small vessels, with promising results (4,5). In this issue of JACC: Cardiovascular Interventions, Siontis et al. (6) report a comprehensive and exhaustive network meta-analysis that summarizes all the evidence currently available from randomized clinical trials on the relative safety and efficacy of different coronary interventions in small vessels. This group from the University of Bern previously reported several elegant network meta-analyses disclosing relevant evidence on the relative efficacy of different interventions in distinct anatomic and clinical scenarios (7). The statistical approach used in network meta-analyses is able to incorporate, to the classic evidence derived from direct comparisons, information from the indirect evidence emerging from interventions that have never been directly compared (8). This methodology not only estimates the relative effectiveness between interventions never compared in head-to-head studies but also provides a hierarchy analysis ranking interventions (8). All available information is eventually synthesized to increase precision in the selected outcome estimates. The present work addresses the conundrum of interventions in small coronary vessels. A total of 19 randomized clinical trials, including 5,072 patients, were analyzed (6). The primary angiographic outcome measure was percentage diameter stenosis at followup. This represents a well-accepted surrogate angiographic endpoint to compare different (namely, balloon vs. stent based) interventional modalities. Long-term angiographic data were available from 16 trials including 4,349 patients. Five interventions (sirolimus-eluting stents [SES], paclitaxel-eluting stents [PES], BMS, DCB, and BA) were evaluated. However, no trial evaluating new-generation DES could be identified. SES provided the best clinical and angiographic results and were ranked as the most effective treatment regarding diameter stenosis, followed by PES and DCB. Both BMS and BA provided poorer clinical and angiographic results. Consideringbinary restenosis rates, SES remained the best-ranked intervention, and SES, PES, and DCB were si...

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“…Most ischaemic endpoints are caused by in-stent restenoses, which generally are more frequent in small than in large coronary vessels because the absolute lumen loss after stent implantation comprises a larger proportional percentage of the total lumen diameter. Previous studies in small vessel disease have shown that drug-eluting stents (DES) are superior to bare metal stents (BMS) regarding both angiographic results and clinical events [1–3], a finding that was corroborated in a recent meta-analysis [4]. While rates for recurrent ischaemic events after implantation of DES are between 5% and 25% with somewhat better results for “limus”- than paclitaxel-eluting stents in a general population [5–8], there was equipoise between “limus”- and paclitaxel-eluting stents in the subgroup of patients with diabetes mellitus, who normally suffer from small vessel disease [9–11].…”

Section: Introductionmentioning

confidence: 89%

First-generation paclitaxel- vs. second-generation zotarolimus-eluting stents in small coronary arteries: the BASKET-SMALL Pilot Study

Jeger¹,

Pfisterer²,

Pfister³

et al. 2016

pwki

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IntroductionEvent rates after percutaneous coronary interventions (PCI) are higher in small than large coronary vessels but may vary between different drug-eluting stent (DES) types.AimTo assess the efficacy of two different DES in small vessel disease.Material and methodsPatients with small vessel PCI were randomised 1 : 1 to a first-generation paclitaxel- vs. a second-generation zotarolimus-eluting stent. The primary endpoint was a composite of cardiac death, non-fatal myocardial infarction, and target vessel revascularisation after 2 years.ResultsOverall, 191 patients were enrolled: 100 with a paclitaxel- and 91 with a zotarolimus-eluting stent. Baseline characteristics were similar in both groups. After 2 years, rates of the primary endpoint were numerically higher for zotarolimus- than paclitaxel-eluting stents (9.9% vs. 5.0%, hazard ratio 2.09, 95% confidence interval (CI) 0.7–6.2, p = 0.19), which was mainly driven by higher rates of target vessel revascularisation (6.6% vs. 2.0%, hazard ratio 3.39, 95% CI: 0.68–16.78, p = 0.14). Based on this, a total of 1,019 patients would be necessary to demonstrate at least non-inferiority between the DES used.ConclusionsIn this pilot study, paclitaxel-eluting stents had a favourable efficacy profile in small vessel disease, although the numbers were too small to draw final conclusions. Based on the prohibitively high sample size for a randomized controlled trial between DES, other treatment options should be considered.

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Percutaneous Coronary Interventions for the Treatment of Stenoses in Small Coronary Arteries

Abstract: Early generation SES yielded the most favorable angiographic and clinical outcomes for the treatment of stenoses in small coronary arteries. New generation DES need to be evaluated against this standard in future randomized trials.

Cited by 70 publications

References 52 publications

A propensity score matched comparative study between paclitaxel‐coated balloon and everolimus‐eluting stents for the treatment of small coronary vessels

A propensity score matched comparative study between paclitaxel‐coated balloon and everolimus‐eluting stents for the treatment of small coronary vessels

Optimal Coronary Interventions in Small Vessels

First-generation paclitaxel- vs. second-generation zotarolimus-eluting stents in small coronary arteries: the BASKET-SMALL Pilot Study

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