doi: 10.1161/01.CIR.0000162512.06704.36
(Circulation. 2005;111:e265-e266.)
© 2005 American Heart Association, Inc.
Correspondence |
Letter Regarding Article by Sawhney et al, "Treatment of Left Anterior Descending Coronary Artery Disease With Sirolimus-Eluting Stents"
Thoraxcentre, Groningen University Hospital, Groningen, the Netherlands
Sawhney et al1 describe a superior adverse cardiac event rate of 9.8% with sirolimus-eluting stents (SES) versus 24.9% with bare metal stents in left anterior descending coronary artery (LAD) disease after 1-year follow-up. Their subgroup analysis of patients with isolated proximal LAD lesions (29.3%) shows similar results because of a reduced in-stent restenosis rate after SES.1 They conclude that long-term SES results might be similar to those of surgically treated LAD lesions.1
Until now, the major randomized SES studies (RAVEL and SIRIUS) reported superior results after SES compared with bare metal stents in less complex lesions. Being a SIRIUS substudy, the article by Sawhney et al reports the results of mainly tubular type B lesions (69.7%).1 Recently, a nonrandomized SES study showed a 9.7% major adverse real-world cardiac event rate at 1 year if SES were applied in consecutive de novo lesions.2 In addition, an angiographic 6-month follow-up study evaluating restenosis after SES deployment identified in-stent restenosis, ostial location, diabetes mellitus, total stent length (per 10 mm increasing), reference diameter (per 1.0 mm increasing), and LAD location as independent multivariate predictors for restenosis.3 Thus, it can be assumed that SES may be an alternative for bypass surgery in patients with type A and B lesions of the proximal LAD in the short term; long-term results of SES in complex lesions of the proximal LAD have not yet been reported.
Patients with complex lesions in the proximal LAD may have an excellent alternative in off-pump coronary surgery. At the 4-year follow-up of a randomized trial, we found a cardiac and cerebrovascular event rate of only 9.8% after off-pump arterial grafting of the LAD in this patient subset.4 Therefore, we conclude that off-pump arterial grafting of these lesions is still an excellent treatment option. Whether SES provides the same long-term results as bypass surgery in this patient subset remains to be proven by a study designed for this comparison.
We agree with Sawhney et al that SES are a major breakthrough in PCI technology. Whether these stents can approach the excellent long-term results of arterial grafting remains to be seen.
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 Top References References |
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1. Sawhney N, Moses JW, Leon MB, Kuntz RE, Popma JJ, Bachinsky W, Bass T, DeMaio S, Fry E, Holmes DR Jr, Teirstein PS. Treatment of left anterior descending coronary artery disease with sirolimus-eluting stents. Circulation. 2004; 110: 374–379.
2. Lemos PA, Serruys PW, Van Domburg RT, Saia F, Arampatzis CA, Hoye A, Degertekin M, Tanabe K, Daemen J, Liu TK, McFadden E, Sianos G, Hofma SH, Smits PC, van der Giessen WJ, de Feyter PJ. Unrestricted utilization of sirolimus-eluting stents compared with conventional bare stent implantation in the "real world": the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. Circulation. 2004; 109: 190–195.
3. Lemos PA, Saia F, Ligthart JM, Arampatzis CA, Sianos G, Tanabe K, Hoye A, Degertekin M, Daemen J, McFadden E, Hofma S, Smits PC, de Feyter P, van der Giessen WJ, van Domburg RT, Serruys PW. Coronary restenosis after sirolimus-eluting stent implantation: morphological description and mechanistic analysis from a consecutive series of cases. Circulation. 2003; 108: 257–260.
4. Drenth DJ, Veeger NJ, Grandjean JG, Mariani MA, van Boven AJ, Boonstra PW. Isolated high-grade lesion of the proximal LAD: a stent or off-pump LIMA? Eur J Cardiothorac Surg. 2004; 25: 567–571.
Response
Division of Cardiology, Scripps Clinic, San Diego, Calif
Cardiovascular Research Foundation, New York, NY
Harvard Clinical Research Institute, Boston, Mass
Brigham and Women’s Hospital, Boston, Mass
Harrisburg Hospital, Harrisburg, Pa
University of Florida, Jacksonville, Fla
Seton Medical Center, Austin, Tex
St. Vincent’s Hospital, Indianapolis, Ind
Mayo Clinic, Rochester, Minn
We thank Dr Drenth and colleagues for their comments on our article.1 We agree that the majority of patients enrolled in the SIRIUS trial had type B lesions; however, 24% had type C lesions. These patients had results similar to the entire SIRIUS cohort with 99% procedural success, a binary in-stent restenosis rate of 5.3%, and a survival free of target lesion revascularization (TLR) rate of 91% at 1 year. Furthermore, 3-year follow-up data have been presented from the RAVEL trial with a sustained 95% rate of survival free from TLR.2 The 2-year SIRIUS data found similar sustained benefit, with a 94% rate of survival free from TLR.3 Numerous randomized controlled trials and registries designed to study outcomes of sirolimus stenting in various complex lesion subsets are ongoing or have been completed recently. Each patient and lesion subset will need careful short- and long-term evaluation. We agree that surgery is always an option for patients. Although it has theoretical advantages, the benefit of off-pump surgery has failed to be conclusively demonstrated in several randomized clinical trials.4–6 We therefore maintain our assertion that sirolimus-eluting stents have narrowed the reintervention gap between surgery and percutaneous intervention.
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References |
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TopReferencesReferences |
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1. Sawhney N, Moses JW, Leon MB, Kuntz RE, Popma JJ, Bachinsky W, Bass T, DeMaio S, Fry E, Holmes DR Jr, Teirstein PS. Treatment of left anterior descending coronary artery disease with sirolimus-eluting stents. Circulation. 2004; 110: 374–379.
2. Fajadet J, Morice MC, Bode C, Barragan P, Serruys PW, Wijns W, Constantini CR, Guermonprez JL, Eltchaninoff H, Blanchard D, Bartorelli A, Laarman GJ, Perin M, Sousa JE, Schuler G, Molnar F, Guagliumi G, Colombo A, Ban Hayashi E, Wulfert E. Maintenance of long-term clinical benefit with sirolimus-eluting coronary stents: three-year results of the RAVEL trial. Circulation. 2005; 111: 1040–1044.
3. Moses J, et al. DES Revolution III: Lessons from SIRIUS with new subset analysis. Presented at the American College of Cardiology 2004.
4. Nathoe HM, van Dijk D, Jansen EW, Suyker WJ, Diephuis JC, van Boven WJ, de la Riviere AB, Borst C, Kalkman CJ, Grobbee DE, Buskens E, de Jaegere PP; Octopus Study Group. A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients. N Engl J Med. 2003; 348: 394–402.
5. Straka Z, Widimsky P, Jirasek K, Stros P, Votava J, Vanek T, Brucek P, Kolesar M, Spacek R. Off-pump versus on-pump coronary surgery: final results from a prospective randomized study PRAGUE-4. Ann Thorac Surg. 2004; 77: 789–793.
6. Legare JF, Buth KJ, King S, Wood J, Sullivan JA, Friesen CH, Lee J, Stewart K, Hirsch GM. Coronary bypass surgery performed off pump does not result in lower in-hospital morbidity than coronary artery bypass grafting performed on pump. Circulation. 2004; 109: 887–892.
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