(Circulation. 1997;96:3873-3879.)
© 1997 American Heart Association, Inc.
Articles |
Long-term Angiographic and Clinical Outcome of Patients Undergoing Multivessel Coronary Stenting
From the Centro Cuore Columbus (B.R., C. Di M., L. Di F., M.F., A.C.), Milan, Italy, and Lenox Hill Hospital (I.M., J.M.), New York, NY.
Correspondence to Antonio Colombo, MD, Centro Cuore Columbus, Via M Buonarotti 48, 20145 Milan, Italy.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background Randomized clinical trials have shown that multivessel coronary angioplasty is feasible and provides similar long-term survival as bypass surgery in selected patients. However, the higher need for repeat intervention, in particular, coronary artery bypass graft surgery, remains a problem. The objective of this study was to test the hypothesis that multivessel stenting is safe and effective in reducing the need for repeat interventions, in particular, the need for bypass surgery.
Methods and Results Between March 1993 and June 1995, 100
consecutive patients (243 lesions) had multivessel coronary
stenting. High-pressure stent optimization was used in all patients.
Procedural success was achieved in 97% of lesions; 2 patients (2%)
required emergency bypass surgery. Angiographic follow-up was obtained
in 89% of patients at 5.2±2.5 months. Angiographic restenosis
occurred in 22% of the lesions, but 37% of patients had 
1 lesion
with restenosis. Clinical follow-up was obtained in all
patients at 21±10 months: target lesion
revascularization was needed in 30 patients (30%),
repeat angioplasty in 28 patients (28%) and coronary bypass
surgery in 2 patients (2%); the overall survival rate was 96% (2%
noncardiac death).
Conclusions Multivessel coronary stenting can be performed with high success rate and low need for emergency bypass surgery. Compared with historical results with multivessel percutaneous transluminal coronary angioplasty, patients who undergo multivessel stenting need less repeat interventions, in particular, less coronary bypass surgery and have similar long-term survival.
Key Words: angioplasty • revascularization • follow-up studies • stents
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Coronary artery bypass graft surgery, originally introduced in 1968,1 results in longer survival and a better quality of life in a specific subgroup of patients with multivessel coronary artery disease compared with the use of an initial strategy of medical therapy.2–5 Prospective, randomized clinical trials6–11 have demonstrated that in patients with multivessel disease with an anatomy suitable for both PTCA and CABG, an initial strategy of PTCA results in a similar incidence of MI or death. However, the PTCA group had a higher incidence of recurrent angina and greater need for repeat revascularization secondary to higher restenosis rate. On the other hand, coronary stenting has been shown to be an effective device in two areas: bailout after failed PTCA12 and reduction of restenosis in selected lesions.13,14 In addition, improvements in deployment technique15,16 and in pharmacological therapy17,18 after stenting have increased its overall efficacy and cost effectiveness. Little data are available on the safety and long-term efficacy of coronary stenting without anticoagulation in patients with multivessel disease.
We performed this retrospective study to test the hypothesis that multivessel stenting without anticoagulation is safe and results in a reduced rate of angiographic restenosis and target lesion revascularization compared with historical results obtained with PTCA.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
From March 30, 1993, through June 30, 1995, 988 consecutive patients with 1307 lesions underwent intracoronary stenting at Centro Cuore Columbus Hospital in Milan, Italy. One hundred patients with multivessel coronary disease (69 patients with two-vessel disease and 31 patients with three-vessel disease) with 243 lesions suitable for stent implantation underwent multivessel coronary stenting. All clinical, angiographic, and IVUS data were prospectively collected and entered into a dedicated database. Patients with stenting of unprotected left main coronary artery and patients with left ventricular ejection fraction of <35% were excluded from this analysis.
Stent Implantation Procedure
IVUS-guided intracoronary stenting was performed using
techniques previously described.16 Indications
for coronary stenting were elective in 189 lesions (79%),
including 16 restenotic lesions and 16 chronic total
occlusions; suboptimal result after PTCA in 26 lesions (10%); and
threatened or acute vessel closure in 28 lesions (11%). The
Palmaz-Schatz coronary stent (Johnson & Johnson Interventional
Systems) was the stent most commonly used (133 lesions). Other stents
included Gianturco-Roubin Flexstent (Cook Inc) in 26 lesions, Wiktor
stent (Medtronic Interventional Vascular) in 27 lesions, AVE (Applied
Vascular Engineering, Inc) in 13 lesions, Cordis stent in 9 lesions,
Wallstent (Schneider) in 16 lesions, and a combination of the
Palmaz-Schatz stent and other stents in 19 lesions. Several different
stent types were used because of the complex anatomy (proximal
tortousity, lesions on a bend, long lesions, and so on), which required
different stent designs and lengths to be used.
Coronary Angiography and IVUS Imaging
Coronary angiography was done in a routine manner.
Angiographic measurements were done with digital electronic calipers
(Brown and Sharp) from an optically magnified image in the view that
shows the most severe narrowing. All angiograms were analyzed
by an experienced angiographer who was not involved in the intervention
and who was blinded to the IVUS measurements. Previous studies have
shown that digital calipers correlate closely with computer-assisted
methods, with low interobserver and intraobserver
variabilities.19 In our laboratory, interobserver
reproducibility was assessed by two experienced angiographers who
performed blinded measurements of randomly selected coronary
segments (n=20). Intraobserver reproducibility was based on blinded
measurements performed at a different time. Intraobserver correlation
coefficient (r) was .98 (P<.0001; 95% CI, .96
to .99) for reference measurements and .91 (P<.0001; 95%
CI, .71 to .97) for intrastent minimal luminal diameter. Interobserver
correlation coefficient was .95 (P<.0001; 95% CI, .87 to
.98) for reference measurements and .90 (P<.0001; 95% CI,
.68 to .97) for intrastent minimal luminal diameter. Lesions were
classified according to the modified American College of
Cardiology– American Heart Association
(AHA-ACC) classification.20
IVUS imaging was performed using the Cardiovascular Imaging System (CVIS) with a 3.2F or 2.9F catheter. Validation of quantitative measurements and pathological correlation with ultrasound measurements have been reported.21,22 Online quantitative measurements were performed during the procedure. In our laboratory, the intraobserver and interobserver variabilities of IVUS measurements inside the stent and in the reference segments have been previously reported.16 The cross section with the smallest lumen area inside the stent was selected for measurements for each pass of the IVUS catheter. Measurements in the reference segment were obtained proximal and distal to the stented segment in the closest, most normal-appearing segments. The average reference vessel and lumen cross-sectional areas were calculated as the average of the proximal and distal reference vessel and lumen cross-sectional areas, respectively.
Definitions
Angiographic Definitions
A clinically important lesion was defined as a stenosis
of 50% of the diameter of a vessel with a reference diameter of
>2.0 mm as measured with electronic calipers.
Clinical Events
Death was defined as any death regardless of cause. A Q-wave MI
was defined as new pathological Q waves (>0.4 second) on an ECG in
conjunction with elevation in creatine kinase to greater than twice the
upper limit of normal. A non–Q-wave MI was defined by an elevation of
the cardiac enzymes to greater than twice the upper limit of normal
without the development of new pathological Q waves. Emergency CABG was
defined as CABG involving immediate transfer of the patient from the
catheterization laboratory to the operating room or
within 24 hours of the procedure. Elective CABG was defined as CABG
performed >24 hours after a stent procedure for procedural failure in
the absence of ischemia or evolving MI. Acute thrombosis was
defined as angiographically documented occlusion with TIMI grade 0 or I
flow at the stent site occurring within 24 hours of the stent
procedure. Subacute thrombosis events were angiographically
documented occlusions with TIMI grade 0 or I flow at the stent site
occurring >24 hours after the stent procedure. Repeat angioplasty was
defined as nonemergency angioplasty performed for
symptomatic restenosis.
Follow-up
Short-term follow-up was performed through telephone
conversation with the patient at 1 month. Angiographic follow-up was
planned at 6 months, but patients who had recurrent symptoms or an
event were studied earlier. Long-term clinical follow-up was performed
through telephone conversation with the patient or the referring
physician.
Statistical Analysis
Normally distributed data that are continuous are expressed as
mean±1 SD. Comparisons of continuous variables between groups was
performed with unpaired student's t test. Subgroup
comparison of categorical variables was performed with
2 analysis. Differences were
considered statistically significant at P<.05. The
contribution of clinical, angiographic, and procedural variables to
the outcome variable (restenosis and target lesion
revascularization) was evaluated with logistic
regression analysis. First, univariate
analysis was performed to independently evaluate the
contribution of each relevant variable; then, variables that
were found to be significant in univariate analysis
were entered into a multivariate logistic regression
model to test the relative contribution of each of these variables
to the outcome variable. Values of P<.05 were
considered significant.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Patient Characteristics and Procedural Variables
Patients' clinical characteristics are shown in Table 1
, and baseline angiographic
characteristics are shown in Table 2.
Eleven lesions (5%) had a thrombus, 38 lesions (16%) were located at
bifurcations, and 25 lesions (10%) were located in vessels with severe
proximal tortousity. The mean number of stents implanted per patient
was 3.4±1.7 stents. Coronary stenting was performed in two
vessels in 84 patients (84%) and three vessels in 14 patients (14%).
Two patients (2%) had only one vessel stented (because of stent
delivery failure to the other vessel). The mean number of lesions
stented per patient was 2.4±0.8 with the following distribution: 2
lesions in 66 patients (66%), 3 lesions in 24 patients (24%), 4
lesions in 5 patients (5%), and 5 lesions in 3 patients (3%). The
mean number of stents implanted per lesion was 1.4±0.9 with the
following distribution: for 10 lesions (4%), one-half Palmaz-Schatz
stent was implanted; for 147 lesions (60%), 1 stent was implanted; for
60 lesions (25%), 2 stents were implanted; and for 24 lesions (10%),
3 stents were implanted. The balloon-to-vessel ratio used for final
stent expansion was 1.13±0.17 with a maximal balloon inflation
pressure of 16±3 atm. Initial stent implantation was angiographically
successful in 235 lesions (97%). Of the study population, 6 patients
had 6 additional lesions (not included in this analysis) for
which PTCA was performed only because they were judged unsuitable for
stent implantation.
|
|
Angiographic and IVUS Analysis
Baseline and postprocedural angiographic measurements are shown in
Table 3. IVUS interrogation after
stenting was performed in 207 lesions (85%). Postprocedural intrastent
minimum lumen diameter was 2.80±0.56 mm, and intrastent minimum
lumen cross-sectional area was 7.40±2.88
mm2, which is larger than the distal reference
lumen cross-sectional area of 6.90±3.08 mm2
(P=.008).
|
Procedural and In-Hospital Events
As shown in Table 4, there were no
procedural deaths. Two patients (2%) underwent emergency CABG: 1 for
vessel rupture and the second for acute closure that was managed with
stenting but with suboptimal results. Six patients (6%) had
non–Q-wave MI, and 2 other patients (2%) had Q-wave MI.
|
In-hospital events occurred in 3 patients (3%); 1 patient had acute stent thrombosis 16 hours after the procedure that was managed with urgent PTCA without further clinical events. A second patient developed arterial thrombosis at the puncture site. This patient underwent surgical embolectomy but had a complicated course with sepsis that resulted in the patient's death. A third patient underwent elective CABG 24 hours after the procedure because of a suboptimal result after multivessel bailout stenting of the left main and left anterior descending coronary artery.
Postprocedural Pharmacological Regimen and Early
Events
Ninety-five patients (95%) were treated with only
antiplatelet medications: ticlopidine and aspirin in 68 patients
(68%) and aspirin alone in 27 patients (27%). Five patients (5%)
received a standard anticoagulation regimen consisting of short-term
heparin, warfarin for 1 month, and aspirin indefinitely. This latter
group included 1 patient with thrombus and slow flow after the
procedure, a second patient with suboptimal final IVUS results, a third
patient with inadequate lesion coverage because of the inability to
deliver the stent, and 2 patients who were receiving chronic
anticoagulants for other indications. Early events within 1 month after
hospital discharge occurred in 1 patient (1%) who had subacute
stent thrombosis with angiographic documentation and died in the
catheterization laboratory before intervention.
Incidence and Predictors of Angiographic Restenosis
Eighty-four of 94 eligible patients (89%) with 226 lesions (89%)
had angiographic follow-up at a mean duration of 5.2±2.5 months
(range, 2.1 to 30 months). The overall incidence of restenosis
expressed on a per-lesion basis was 22%, but 31 patients (37%) had
1 lesion with restenosis. As shown in Table 5, restenotic lesions were
located in smaller vessels and had smaller postprocedural minimum lumen
diameter as determined with angiography and IVUS. There was no
significant difference in stent type, stent indication, number of
stents per lesion, balloon-to-vessel ratio, or maximal pressure used
for stent optimization. Table 6 shows
predictors of restenosis as evaluated with
univariate and multivariate logistic
regression analyses.
|
|
Repeat Interventions and Long-term Clinical Events
Clinical follow-up was achieved in all patients at 21±10 months.
Repeat revascularization at the target lesion site
was required in 30 patients (30%), PTCA was required in 28 patients
(28%), and CABG was required in 2 patients (2%). Predictors of the
need for target lesion revascularization are shown
in Table 7. Other events included 1
patient (1%) who underwent CABG after failed angioplasty for a new
lesion and 2 patients (2%) had nonfatal MI. In addition, 2 patients
(2%) died; the first occurred 8 months after the procedure secondary
to MI, and the second patient died 1 year after the procedure secondary
to pulmonary embolism. Of 89 patients who were alive and free
from CABG at long-term follow-up, 8 patients had angina (9%). There
were 75 patients (84%) who had treadmill stress tests, and 3 of these
patients (4%) had objective evidence of ischemia.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Scope of the Problem: Lessons Learned From Prospective, Randomized Clinical Trials
The results of several prospective, randomized clinical trials have recently shed light on an issue that has been under debate for a decade—the value of PTCA compared with CABG in treatment of patients with multivessel coronary disease. Table 8
lists the results of these trials. In
patients who were randomized to PTCA, the need for in-hospital CABG
ranged from 5% to 10.1% (emergency CABG ranged from 4.3% to 9.6%).
At long-term follow-up, the need for target lesion
revascularization ranged from 37% to 55% (with
the need for CABG ranging from 16% to 22.5%), and cumulative
mortality ranged from 2.2% to 13.7%. These results were later
confirmed in a large meta-analysis of eight randomized trials
in which PTCA was compared with CABG in single and multivessel
disease.23 In a subset of this analysis
(patients with multivessel disease, not including BARI), a total of
1336 patients who were randomized to PTCA were compared with 1303
patients randomized to CABG. Among patients randomized to PTCA, 4.6%
required emergency CABG, 18.3% required additional CABG within 1 year,
and in subsequent years the need for additional CABG was 2% per year.
Data from these trials indicate that patients randomized to an initial
strategy of PTCA had an equivalent incidence of nonfatal MI and death
compared with patients undergoing CABG but a higher recurrence
of angina and repeat interventions. This led to a better quality of
life in the CABG group at 3 years follow-up after the initial morbidity
caused by the procedure. In addition, the escalating costs of repeat
interventions over 5-year follow-up in the PTCA group led to similar
costs as for CABG in patients with three-vessel
disease.24
|
In light of these data, it becomes clear that for catheter-based coronary interventions to gain an edge in the treatment of this important cohort of patients, an improvement in these results is needed. Coronary stenting has been shown to be an effective device for bailout after failed PTCA, reducing the need for emergency CABG.25 In addition, coronary stenting has expanded the therapeutic window to more complex lesions, such as chronic total occlusions,26–28 ostial lesions,29,30 and calcified lesions,31 with more favorable immediate- and long-term outcomes compared with PTCA. With this background, our experience in the treatment of multivessel coronary artery disease with coronary stenting can be put into better perspective.
Present Study: `The Stenting Alternative'
Multivessel Stenting: Procedural Safety, Outcome, and Completeness
of Revascularization
It has been shown that procedural safety and outcome in
catheter-based coronary interventions are influenced by vessel
size, lesion length, lesion location, and overall lesion
complexity.32,33 In this study, 42% of lesions
were located in vessels of <3.0 mm, 19% of lesions were
>15 mm, 7% of lesions were chronic total occlusions, and 9% of
lesions were ostial. Type B2 and C lesions were present in 60% of
cases. Despite this complex lesion subset, successful stent deployment
was achieved in 97% of cases. In-hospital events included Q-wave MI in
2 patients (2%), emergency CABG in 2 patients (2%), elective CABG in
1 patient (1%), and death in 1 patient (1%). Procedural success and
complications in this study are similar to results obtained with
one-vessel stenting.16 However, these results
represent an improvement from results obtained with multivessel
PTCA, in particular with regard to the reduction in the need for
in-hospital CABG, which ranged between 5% and 10%, as shown in Table 8
.7–11 In addition, the results of the
present study are consistent with other reports on
multivessel stenting. Laham et al34 reported
results of multivessel Palmaz-Schatz stenting in 103 patients (212
vessels). Angiographic success was achieved in 210 vessels. Non–Q-wave
MI occurred in 11 patients, Q-wave MI occurred in 2 patients, and 1
patient died. There was no emergent CABG and no stent thrombosis.
With regard to the issue of completeness of revascularization, great variability exists in the literature in regard to its definition and impact on cardiac events and survival. Bourassa et al35 reported on reasons for incomplete revascularization in the National Heart, Lung, and Blood Institute PTCA registry; those included chronic total occlusions, complex lesions, and operator decision not to dilate nonculprit lesions. With progress in angioplasty technique and equipment, operators became more aggressive, but complete revascularization remained less than what was expected with CABG. In our study, complete revascularization was achieved in all 69 patients (100%) with two-vessel disease and 21 of 31 patients with three-vessel disease (68%). However, the impact of completeness of revascularization on cardiac events and survival remains unclear. Bell et al36 suggested that the main advantage of complete revascularization in patients undergoing CABG occurs in patients with impaired left ventricular function and severe angina.
Stent Thrombosis and Stent Restenosis in Multivessel
Stenting
The incidence of stent thrombosis has declined with improvements
in stent implantation technique15,16 and
pharmacological therapy17,18 in patients with
one-vessel stenting. Little data are available on the incidence of
stent thrombosis with multivessel stenting. In this study, stent
thrombosis occurred in 2 lesions (0.8%) in 2 patients (2%), which is
similar to rates reported with one vessel stenting in the era of
high-pressure stent deployment with antiplatelet therapy. This
demonstrates that stenting several lesions in a patient does not
increase the risk of stent thrombosis if the appropriate technique is
used.37,38
Angiographic follow-up was performed in 89% of eligible patients at
5.2±2.5 months. Angiographic restenosis on a per-lesion basis
was 22%; however, 31 patients (37%) had one or more lesions with
restenosis: 23 patients (74%) had only 1 lesion with
restenosis, 4 patients (13%) had 2 lesions with
restenosis, and 4 patients (13%) had 3 lesions with
restenosis. The Figure shows te linear
relationship between the number of stented lesions and the number of
restenotic lesions (per patient). These results, if confirmed
in larger studies, might help guide decision making with regard to the
probability of restenosis according to the number of lesions
that must be treated.
|
Repeat Interventions and Clinical Events at Long-term
Follow-up
In the present study, long-term clinical follow-up was
performed in all patients at 21±10 months. A total of 30 patients
(30%) needed target lesion revascularization for
1 lesion (28 patients needed PTCA and 2 patients needed CABG). The
fact that only 2 patients needed CABG at follow-up is clearly a major
advantage over multivessel PTCA, for which the need for CABG at
long-term follow-up ranged from 16% to 31%, as shown in Table 8.7–11 The reason for the lower need for CABG in
the present study is because the majority of patients with
restenosis had only 1 culprit lesion that was easily managed
with repeat angioplasty. The long-term outcome for patients undergoing
repeat angioplasty for instent restenosis remains a subject of
debate, but data point to a favorable long-term outcome, particularly
in patients with focal restenosis. Reimers et
al39 reported the long-term clinical outcome for
119 patients who underwent repeat balloon angioplasty for instent
restenosis. In this series, only 10% of patients needed repeat
target lesion revascularization for clinical
restenosis.
To summarize, the present study demonstrates that patients who underwent multivessel coronary stenting have a favorable long-term outcome. The overall cumulative survival was 96% (2% noncardiac death), CABG-free survival was 89%, CABG-and-MI–free survival was 87%, and angina-free survival was 87%.
Cost Considerations
Cost effectiveness is an important factor in decision making in
medicine. Cohen et al40 reported a cost
effectiveness comparison between one-vessel coronary stenting
and one-vessel PTCA in the STRESS trial. At 1 year, stenting was found
to cost 800$ more per patient compared with PTCA. This increase in cost
was due to higher vascular complications and longer hospital stay. In
our study, no cost calculations were made, but with the use of only
antiplatelet therapy in 95% of patients, there was only a 1%
incidence of vascular complication and all patients who had successful
stenting were discharged home within 2 days. These developments
in coronary stenting may result in cost savings, and future
trials investigating this issue will provide the needed data.
Study Limitations
The results of this study should be interpreted in the context of
several limitations. This is a retrospective analysis with an
inherent selection bias for patients judged appropriate for
coronary stenting. Even though the Palmaz-Schatz stent was the
stent most commonly used, different stent designs were used for
different indications, which might limit the ability to extrapolate
data regarding outcome associated with different stent types. However,
different stent types may be needed to provide a successful and
complete revascularization in many patients with
complex coronary anatomy. Despite these limitations,
this study provides an insight into the angiographic and clinical
outcomes for patients undergoing multivessel stenting.
Conclusions
This study describes the results of coronary artery
stenting when used as an initial strategy to treat patients with
multivessel coronary disease. This approach is safe; it is
associated with a high success rate and a low need for emergency CABG.
In addition, compared with historical results of multivessel PTCA,
there is a modest decrease in the need for repeat interventions
(combined angioplasty and CABG) and a significant decrease in the need
for repeat CABG at long-term follow-up. These observations must be
confirmed with randomized clinical trials to provide clinicians with
guidance regarding the best strategy of treatment for this increasingly
important patient population.
|
Selected Abbreviations and Acronyms |
|---|
|
Received May 8, 1997; revision received August 6, 1997; accepted August 21, 1997.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1. Favaloro RG. Saphenous vein autograft replacement of severe segmental coronary artery occlusion: operative technique. Ann Thorac Surg. 1968;5:334–339.[Medline] [Order article via Infotrieve]
2. The Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group. Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med. 1984;311:333–339.[Medline] [Order article via Infotrieve]
3. Varnauskas E, European Coronary Surgery Study Group. Twelve-year follow-up of survival in the randomized European Coronary Surgery Study. N Engl J Med. 1988;319:332–337.[Abstract]
4.
Alderman EL, Bourassa MG, Cohen LS, Davis KB, Kaiser
GG, Killip T, Mock MB, Pettinger M, Robertson TL. Ten-year follow-up of
survival and myocardial infarction in the randomized Coronary
Artery Surgery Study. Circulation. 1983;68:939–950.
5. Passamani E, Davis KB, Gillespie MJ, Killip T, CASS Principal Investigators. A randomized trial of coronary artery bypass surgery: survival in patients with a low ejection fraction. N Eng J Med. 1985;312:1665–1671.[Abstract]
6. Rodriguez A, Boullon F, Perez Balino N, Liprandi MI, Paviotti C. Argentine randomized trial of percutaneous transluminal coronary angioplasty versus coronary artery bypass surgery in multivessel coronary disease (ERACI). J Am Coll Cardiol. 1993;22:1060–1067.[Abstract]
7. RITA Trial Participants. Coronary angioplasty versus coronary artery bypass surgery: the Randomized Interventional Treatment of Angina (RITA) Trial. Lancet. 1993;341:573–580.[Medline] [Order article via Infotrieve]
8.
Hamm CW, Reimers J, Ischinger T, Rupprecht H-J, Berger
J, Bleifeld W, for the GABI Study Group. A randomized study of
coronary angioplasty compared with bypass surgery in patients
with symptomatic multivessel coronary disease.
N Engl J Med. 1994;331:1037–1043.
9.
King SB, Lembo NJ, Weintraub WS, Kosinski AS, Barnhart
HX, Kutner MH, Alazraki MP, Guyton RA, Zhao XQ, for the EAST trial. A
randomized trial comparing coronary angioplasty with
coronary bypass surgery. N Engl J Med. 1994;331:1044–1050.
10. CABRI Trial Participants. First-year results of CABRI (Coronary Angioplasty versus Bypass Revascularization Investigation). Lancet. 1995;346:1179–1184.[Medline] [Order article via Infotrieve]
11.
Bypass Angioplasty
Revascularization Investigation (BARI)
Investigators. Comparison of coronary bypass surgery with
angioplasty in patients with multivessel disease. N Engl
J Med. 1996;335:217–225.
12.
Roubin GS, Cannon AD, Agrawal SK, Macander PJ, Dean LS,
Baxley WA, Breland J. Intracoronary stenting for acute or
threatened closure complicating percutaneous
transluminal coronary angioplasty. Circulation.. 1992;85:916–927.
13.
Fischman D, Leon M, Baim D, Schatz R, Savage M, Penn I,
Detre K, Veltri L, Ricci D, Nobuyoshi M, Cleman M, Heuser R, Almond D,
Teirstein P, Fish D, Colombo A, Brinker J, Moses J, Shaknovich A,
Hirshfeld J, Baily S, Ellis S, Rake R, Goldberg S. A randomized
comparison of coronary stent placement and balloon angioplasty
in the treatment of coronary artery disease. N Engl
J Med.. 1994;331:496–501.
14.
Serruys P, Jaegere P, Kiemeneij F, Macaya C, Rutsch W,
Heyndrickx G, Emanuelsson H, Marco J, Legrand V, Materne P, Belardi J,
Sigwart U, Colombo A, Goy JJ, Heuvel P, Delcan J, Morel M. A comparison
of balloon expandable stent implantation with balloon angioplasty in
patients with coronary artery disease. N Engl J
Med.. 1994;331:489–495.
15.
Nakamura S, Colombo A, Gaglione S, Almagor Y, Goldberg
SL, Maiello ML, Finci L, Tobis JM. Intracoronary ultrasound
observations during stent implantation. Circulation.. 1994;89:2026–2034.
16.
Colombo A, Hall P, Nakamura S, Almagor Y, Maiello L,
Martini G, Gaglione A, Goldberg SL, Tobis J. Intracoronary
stenting without anticoagulation accomplished with intravascular
ultrasound guidance. Circulation.. 1995;91:1676–1688.
17.
Schomig A, Neumann FJ, Kastrati A, Schuhlen H, Blasini
R, Hadamitzky M, Walter H, Zitzman-Roth EM, Richardt G, Alt E, Schmitt
C, Ulm K. A randomized comparison of antiplatelet and anticoagulant
therapy after the placement of coronary artery stents.
N Engl J Med.. 1996;334:1084–1089.
18.
Karrillon GJ, Morice MC, Benveniste E, Bunouf P, Aubry
P, Cattan S, Chevalier B, Commeau P, Cribier A, Eiferman C, Grollier G,
Guerin Y, Henry M, Lefevre T, Livarek B, Louvard Y, Marco J, Makowski
S, Monassier JP, Pernes JM, Rioux P, Spaulding C, Zemour G.
Intracoronary stent implantation without ultrasound guidance
and with replacement of conventional anticoagulation by
antiplatelet therapy. Circulation.. 1996;94:1519–1527.
19. Scoblianco DP, Brown G, Mitten S. A new digital electronic caliper for measurement of coronary arterial stenosis: a comparison with visual and computer-assisted measurements. Am J Cardiol.. 1984;53:689–693.[Medline] [Order article via Infotrieve]
20.
Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB III,
Loop FD, Peterson KL, Reeves TJ, Williams DO, Winters WL Jr. Guidelines
for percutaneous transluminal coronary
angioplasty: a report of the American College of
Cardiology/American Heart Association Task Force on
assessment of diagnostic and therapeutic
cardiovascular procedures. Circulation.. 1988;78:486–502.
21.
Tobis JM, Mallory J, Mahon D, Lehman K, Zalesky P,
Griffith J, Henry WL. Intravascular ultrasound imaging of human
coronary arteries in vivo: analysis of tissue
characteristics with comparison to in vitro histologic specimens.
Circulation.. 1991;83:913–926.
22. Nishimura RA, Edwards WD, Warnes CA, Reeder GS, Holmes DR Jr, Tajik AJ, Yock PJ. Intravascular ultrasound imaging: in vitro validation and pathologic correlation. J Am Coll Cardiol.. 1990;16:145–154.[Abstract]
23. Pocock SJ, Henderson RA, Richards AF, Hampton JR, King SB, Hamm CW, Puel J, Hueb W, Goy JJ, Rodriguez A. Meta-analysis of randomized trials comparing coronary angioplasty with bypass surgery. Lancet. 1995;346:1184–1189.[Medline] [Order article via Infotrieve]
24.
Hlatky M, Rogers W, Johnstone I, Boothroyd D, Brooks
MM, Pitt B, Reeder G, Ryan T, Smith H, Whitlow P, Wiens R, Mark D, for
the Bypass Angioplasty Revascularization
Investigation (BARI) Investigators. Medical care costs and quality of
life after randomization to coronary angioplasty or
coronary bypass surgery. N Engl J Med. 1997;336:92–99.
25. Lincoff AM, Topol EJ, Chapekis AT, George BS, Candela RJ, Muller DW, Zimmerman CA, Ellis SG. Intracoronary stenting compared with conventional therapy for abrupt vessel closure coplicating coronary angioplasty: a matched case-control study. J Am Coll Cardiol. 1993;21:866–875.[Abstract]
26. Goldberg SL, Colombo A, Maiello L, Borrione M, Finci L, Almagor Y. Intracoronary stent insertion after balloon angioplasty of chronic total occlusions. J Am Coll Cardiol. 1995;26:713–719.[Abstract]
27. Moussa I, Di Mario C, Di francesco L, Reimers B, Blengino S, Martini G, Tobis J, Colombo A. Coronary stenting of chronic total occlusions without anticoagulation: immediate and long-term outcome. Eur Heart J. 1996;17:P2451.
28. Sirnes P, Golf S, Myreng Y, Molstad P, Emanuelsson H, Albertsson P, Brekke M, Mangschau A, Endersen K, Kjekshus J. Stenting in Chronic Coronary Occlusion (SICCO): A randomized, controlled trial of adding stent implantation after successful angioplasty. J Am Coll Cardiol. 1996;28:1444–1451.[Abstract]
29. Rocha-Singh K, Morris N, Wong SC, Schatz RA, Teirstein PS. Coronary stenting for treatment of ostial stenoses of native coronary arteries or aorto-coronary saphenous vein grafts. Am J Cardiol.. 1995;75:26–29.[Medline] [Order article via Infotrieve]
30. Zampieri P, Colombo A, Almagor Y, Maiello L, Finci L. Results of coronary stenting of ostial lesions. Am J Cardiol.. 1994;73:901–903.[Medline] [Order article via Infotrieve]
31.
Moussa I, Di Mario C, Moses J, Reimers B, Di Francesco
L, Martini G, Tobis J, Colombo A. Coronary stenting following
rotational atherectomy in calcified and complex lesions: angiographic
and clinical follow-up results. Circulation. 1997;96:128–136.
32. Sharma S, Israel D, Kamean J, Bodian C, Ambrose J. Clinical, angiographic, and procedural determinants of major and minor coronary dissections during angioplasty. Am Heart J.. 1993;126:39–47.[Medline] [Order article via Infotrieve]
33. Myeler R, Shaw R, Stertzer S, Hecht HS, Ryan C, Rosenblum J, Cumberland DC, Murphy MC, Hansell HN, Hidalgo B. Lesion morphology and coronary angioplasty: current experience and analysis. J Am Coll Cardiol.. 1992;19:1641–1652.[Abstract]
34.
Laham R, Cohen D, Carrozza P. Multivessel Palmaz-Schatz
stenting: acute results and one year outcome. Circulation.. 1996;94:1506. Abstract.
35. Bourassa MG, Holubkov R, Yeh W, Detre KM. Strategy of complete revascularization in patients with multivessel coronary disease (a report from the 1985–1986 NHLBI PTCA Registry). Am J Cardiol. 1992;70:174–178.[Medline] [Order article via Infotrieve]
36.
Bell MR, Gersh BJ, Schaff HV, Holmes DR Jr, Fisher L,
Alderman E, Myers W, Parsons L, Reeder G, and the Investigators of the
Coronary Artery Surgery Study. Effect of completeness of
revascularization on long-term outcome of patients
with three-vessel disease undergoing coronary artery bypass
surgery: a report from the Coronary Artery Surgery Study
(CASS). Circulation. 1992;86:446–457.
37. Moussa I, Di Mario C, Di Francesco L, Reimers B, Blengino S, Colombo A. Subacute stent thrombosis and the anticoagulation controversy: changes in drug therapy, operator technique, and the impact of intravascular ultrasound. Am J Cardiol. 1996;78(suppl 3A):13–17.
38. Moussa I, Di Mario C, Reimers B, Akiyama T, Tobis J, Colombo A. Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome. J Am Coll Cardiol. 1997;29:6–12.[Abstract]
39. Reimers B, Moussa I, Di Mario C, Tucci G, Ferraro M, Martini G, Blengino S, Colombo A. Long-term clinical outcome after interventional treatment of stent restenosis. J Am Coll Cardiol. 1997;30:186–192.[Abstract]
40.
Cohen DJ, Krumholz HM, Sukin CA, Ho K, Siegrist R,
Cleman M, Heuser R, Brinker J, Moses J, Savage M, Detre K, Leon M, Baim
D, for the Stent Restenosis Study Investigators. In-hospital
and one-year economic outcomes after coronary stenting or
balloon angioplasty: results from a randomized clinical trial.
Circulation. 1995;92:2480–2487.
This article has been cited by other articles:
 |
|
 |
|
  R. Mehran, G. D. Dangas, Y. Kobayashi, A. J. Lansky, G. S. Mintz, E. D. Aymong, M. Fahy, J. W. Moses, G. W. Stone, and M. B. Leon Short- and long-term results after multivessel stenting in diabetic patients J. Am. Coll. Cardiol., April 21, 2004; 43(8): 1348 - 1354. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. Orlic, E. Bonizzoni, G. Stankovic, F. Airoldi, A. Chieffo, N. Corvaja, G. Sangiorgi, M. Ferraro, C. Briguori, M. Montorfano, et al. Treatment of multivessel coronary artery disease with sirolimus-eluting stent implantation: immediate and mid-term results J. Am. Coll. Cardiol., April 7, 2004; 43(7): 1154 - 1160. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Gimelli, M. Glauber, A. Giorgetti, G. Sambuceti, A. L'Abbate, and P. Marzullo Revascularization of dysfunctioning myocardium: differential prognostic effects of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty in patients with three-vessel disease and mostly viable myocardium Interactive CardioVascular and Thoracic Surgery, September 1, 2003; 2(3): 301 - 306. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Toda, K. Mackenzie, M. R. Mehra, C. J. DiCorte, J. E. Davis, P. M. McFadden, J. L. Ochsner, C. White, and C. H. Van Meter Jr Revascularization in severe ventricular dysfunction (15% <= LVEF <= 30%): a comparison of bypass grafting and percutaneous intervention Ann. Thorac. Surg., December 1, 2002; 74(6): 2082 - 2087. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C.V Patil, E Nikolsky, M Boulos, E Grenadier, and R Beyar Multivessel coronary artery disease: current revascularization strategies Eur. Heart J., July 2, 2001; 22(14): 1183 - 1197. [PDF]
|
|
|
|
|
|
T. Hammoud, J.-F. Tanguay, and M. G. Bourassa Management of coronary artery disease: therapeutic options in patients with diabetes J. Am. Coll. Cardiol., August 1, 2000; 36(2): 355 - 365. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. A. Eagle, R. A. Guyton, R. Davidoff, G. A. Ewy, J. Fonger, T. J. Gardner, J. P. Gott, H. C. Herrmann, R. A. Marlow, W. C. Nugent, et al. ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/ American Heart Association task force on Practice Guidelines (Committee to revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery) J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1262 - 1347. [Full Text] [PDF]
|
|
|
|
 |
|
 M. M Gandhi and K. D Dawkins Fortnightly review: Intracoronary stents BMJ, March 6, 1999; 318(7184): 650 - 653. [Full Text]
|
|
|
|
|
|
R. Kornowski, R. Mehran, L. F. Satler, A. D. Pichard, K. M. Kent, A. Greenberg, G. S. Mintz, M. K. Hong, and M. B. Leon Procedural results and late clinical outcomes following multivessel coronary stenting J. Am. Coll. Cardiol., February 1, 1999; 33(2): 420 - 426. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Elezi, A. Kastrati, F.-J. Neumann, M. Hadamitzky, J. Dirschinger, and A. Schomig Vessel Size and Long-Term Outcome After Coronary Stent Placement Circulation, November 3, 1998; 98(18): 1875 - 1880. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||