(Circulation. 1998;98:1875-1880.)
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports |
Vessel Size and Long-Term Outcome After Coronary Stent Placement
From Deutsches Herzzentrum and 1. Medizinische Klinik rechts der Isar, Technische Universität München, Munich, Germany.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background—The role of coronary stenting in the treatment of patients with small vessels is not well defined. The purpose of this study was to investigate the influence of vessel size on long-term clinical and angiographic outcome after coronary stent placement.
Methods and Results—The study comprised 2602 patients with successful stent implantation for symptomatic coronary artery disease. Patients were subdivided into 3 equally sized groups (tertiles) according to vessel size, with respective ranges of <2.8, 2.8 to 3.2, and >3.2 mm. Event-free survival at 1 year was 69.5% in the group with smaller vessels, 77.5% in the second group, and 81% in the group with larger vessels (P<0.001). Late lumen loss was similar between the 3 groups (1.12±0.73, 1.12±0.79, and 1.09±0.88 mm, respectively). Angiographic restenosis rate was significantly higher in the small-vessel group (38.6%, 28.4%, and 20.4% in groups 1, 2, and 3, respectively; P<0.001). The analysis identified subgroups with different risk for restenosis even among patients with small vessels. Within this group, the restenosis rate may be as low as 29.6% in patients without additional risk factors and as high as 53.5% in patients with diabetes and complex lesions.
Conclusions—Patients with small vessels present a higher risk for an adverse outcome after coronary stent placement because of a higher incidence of restenosis. However, the unusually high risk for restenosis is confined to those patients with small vessels who have concomitant risk factors such as diabetes and complex lesions.
Key Words: : angiography • coronary disease • restenosis • stents • vessels
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Coronary stent placement is an established treatment for patients with symptomatic coronary artery disease.1 2 However, uncertainty about the results of stenting in small vessels has been the reason that only patients with target vessels
3 mm have been included in
randomized trials.1 2 Therefore, stenting is
generally recommended as a treatment option only for larger
vessels.3 Indeed, this constitutes a major
limitation for broadening the indications for coronary stent
implantation. Previous studies with percutaneous
coronary interventions have focused on the influence of vessel
size on angiographic restenosis. Analyses after PTCA
have generally shown an inverse relationship between vessel size and
severity of angiographic restenosis at
follow-up.4 5 Several studies have assessed the
influence of vessel size on angiographic restenosis after
coronary stent placement.6 7 8 9 10 11 12 If the
proposed generalized model of restenosis based on a uniform
late loss/acute gain ratio13 14 is also
applicable to small vessels, stent placement is expected to offer
advantages over the entire range of vessel size because of its better
immediate results. Furthermore, angiographic assessment alone may not
reliably reflect the clinical outcome of these patients. Concerns have
been expressed about the possible dissociation between the angiogram
and clinical outcome.15 It would be of interest
to know whether all patients with smaller vessel size are affected by a
similar risk or whether subgroups with different risks can be
identified among them. Thus, much more information is needed before the
role of coronary stenting in the treatment of patients with
small vessels can be established. The purpose of this study was to investigate the influence of vessel size on clinical and angiographic outcome after successful stent implantation in a large patient population.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Patient Population
The study population comprised all 2602 patients from the Deutsches Herzzentrum and 1. Medizinische Klinik der Technische Universität, Munich, with successful stent placement (stent at the desired position, residual stenosis <30%) during the period from May 1992 through February 1997. Excluded from the study were patients with cardiogenic shock or mechanical ventilation before PTCA. All patients who survived the first month after the procedure with neither stent vessel occlusion nor any other cardiac event (myocardial infarction, coronary bypass surgery, or PTCA) were considered eligible for follow-up angiography at 6 months. Follow-up angiography at a median of 188 days (interquartile range, 173 to 203) was performed in 2017 (80.5%) of the 2506 eligible patients.
Stent Placement
All patients received 15 000 U of heparin and 500 mg of aspirin
intravenously before PTCA. Short, 7-mm or standard
articulated 15-mm Palmaz-Schatz stents (Johnson & Johnson) were
delivered under fluoroscopic guidance after they were hand-crimped on
slightly oversized conventional angioplasty balloons. Adequacy of the
final result was based solely on visual assessment of the stent site in
the angiogram; intravascular ultrasound was used only in a minority of
cases. Poststenting antithrombotic therapy consisted of either oral
anticoagulant (initial phase) or combined antiplatelet therapy, as
previously described.16
Quantitative Angiographic Analysis
Standardized image acquisition was used, consisting of
multiple projections for each lesion, accurately reproduced in each
angiographic session. Before each sequence, intracoronary
injections of 0.1 to 0.3 mg of nitroglycerin were used
to control for vasomotor tone. Quantitative analysis was
performed on the baseline angiogram, on that containing the maximally
inflated balloon, and on final poststenting and follow-up angiograms.
An automated edge-detection algorithm (CMS 3.0, Medis Medical Imaging
Systems) was used to obtain actual balloon diameter, interpolated
reference diameter (RD), minimal lumen diameter (MLD), and diameter
stenosis.
Definitions and Study End Points
Acute gain was calculated as the difference between the final
and the original MLD; late loss was calculated as the difference
between final poststenting MLD and MLD measured at follow-up
angiography. Loss index was the calculated ratio of late loss and acute
gain. Acute gain and late loss were also adjusted for vessel size, and
relative gain and relative loss parameters were obtained.
Binary restenosis was defined as a diameter stenosis
50% at control angiography. Lesions were also qualitatively
classified by use of the modified American College of
Cardiology/American Heart Association grading
system,17 and type B2 and C lesions were
considered complex lesions.
Major adverse cardiovascular events were defined as
death of cardiac or procedure-related origin, nonfatal myocardial
infarction, and target-lesion revascularization
(CABG or repeat PTCA of the stented vessel). All deaths were considered
of cardiac origin unless a noncardiac cause was established by autopsy.
The diagnosis of acute myocardial infarction was made in the presence
of a clinical episode of prolonged chest pain, a rise in serum cardiac
enzyme levels to at least twice the upper normal limit, or the
appearance of 1 new pathological Q wave. Cardiac events were
monitored throughout the follow-up period. The diagnosis of stent
vessel occlusion was always based on symptom-driven or routinely
scheduled coronary angiography in the presence of
Thrombolysis In Myocardial Infarction (TIMI) flow grade 0
or 1.
The primary clinical end point of the study was the probability of event-free survival at 1 year. The primary angiographic end point was restenosis at follow-up as assessed by binary restenosis and late lumen loss. Secondary end points were the occurrence of any major adverse cardiovascular event or stent vessel occlusion during the first 30 days after the procedure.
Statistical Analysis
Statistical analyses were performed with S-Plus
(Mathsoft, Inc) or SPSS statistical software packages on a per-patient
basis. For patients with multilesion interventions, only 1 lesion was
randomly selected for analysis. However, for primary end points
(both clinical and angiographic), this approach was validated through a
repeated analysis confined to patients with single-lesion
intervention. The study population was subdivided into 3 groups
(tertiles) according to RD; the ranges were <2.8 mm for the first
group, 2.8 to 3.2 mm for the second, and >3.2 mm for the
third. Group differences were assessed by ANOVA or Kruskal-Wallis H
test for continuous variables and 
2
analysis for categorical variables.
Multivariate logistic regression was used to assess the
independent role of vessel size in restenosis after adjustment
for other covariates. Event-free survival curves for all cardiac events
and specifically for myocardial infarction were constructed by means of
the Kaplan-Meier method. Survival probabilities of the 3 groups were
compared with log-rank test. In addition, assessment of the independent
role of vessel size in event-free survival was made by use of Cox
proportional hazards regression model and adjustment for other
covariates. A 2 automatic interaction
detection (CHAID) algorithm (SPSS Inc) was used to identify subgroups
of patients with different risk for restenosis within the group
with small vessels.
Data are expressed as mean±SD for continuous variables and as percentages for discrete variables. Differences were considered to be statistically significant when the respective P values were <0.05.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Baseline characteristics of patients are shown in Tables 1
and 2.
|
|
Clinical Outcome
Table 3 shows clinical outcome
during the first 30 days. The incidence of any major adverse
cardiovascular event during this period was 4.5% in
the first group, 3.3% in the second, and 2.9% in the third
(P=0.65). There was a significant difference for repeat PTCA
between the 3 groups, with the highest incidence occurring in the group
with small vessels. In 32% of the patients in the group with small
vessels, the reason for reintervention was a large residual
dissection.
|
After 1 year, the probability of survival free of myocardial infarction
was not significantly different (94.7%, 96.2%, and 95.4% in groups
1, 2, and 3, respectively; P=0.34). There was also no
significant difference between the 3 groups in the probability of
survival free of myocardial infarction when the analysis was
restricted to patients with single-lesion interventions (95.0%,
97.0%, and 95.5% in groups 1, 2, and 3, respectively;
P=0.38). However, the probability of event-free survival was
significantly different (69.5% in the first group, 77.5% in the
second, and 81% in the third; Figure 1).
This was due to a higher rate of repeat PTCA in the first group
(26.3%) compared with the second and third groups (18.8% and 14.3%,
respectively; P<0.001), whereas the rate of CABG was
similar in all 3 groups (2.5% versus 2.2% versus 1.6%;
P=0.41). Significant differences between the 3 groups
(P<0.001) were also recorded for event-free survival
when the analysis was confined to patients with single-lesion
interventions. The results of the Cox proportional hazards regression
model that included 21 explanatory variables demonstrated that
small vessel size is an independent risk factor for the occurrence of
major adverse cardiovascular events during 1 year of
follow-up. Vessel size was entered into the model as a continuous
variable, and a comparison between vessel sizes of 2.7 mm (1st
quartile) and 3.4 mm (3rd quartile) yielded a hazard ratio of 1.56
(95% CI, 1.37 to 1.75). Additional independent risk factors were age,
diabetes, complex lesions, multiple stent placement, and lower
balloon-to-vessel ratio. Figure 2 is a
graphic demonstration of the relation between vessel size and adjusted
risk for an adverse outcome as derived from the Cox model. The risk
shows a gradual increase as vessel size decreases.
|
|
Angiographic Outcome
Subacute stent occlusions occurred in 21 patients (2.4%) in
the first group, 22 (2.5%) in the second group, and 17 (2.0%) in the
third group (Table 3
). Angiographic outcome at 6 months is
presented in Table 4.
Restenosis rate demonstrated a steady decrease as vessel size
increased: 38.6% in the first group, 28.4% in the second, and only
20.4% in the third (P<0.001). Differences in
restenosis rate between the 3 groups remained significant when
the analysis was restricted to patients with single-lesion
intervention (37.0%, 27.3%, and 19.9% in groups 1, 2, and 3,
respectively; P<0.001). Late lumen loss was not
statistically different despite the significant difference in acute
gain observed between the 3 groups. In addition, linear regression
analysis demonstrated that variations in relative gain could
explain <6% of the variability in relative loss.
|
In the multivariate logistic regression model that
included 21 explanatory variables, small vessel size remained a
significant independent risk factor for restenosis, with an
odds ratio of 1.75 (95% CI, 1.49 to 2.08) for a vessel size of 2.7
versus 3.4 mm; additional independent risk factors were diabetes,
previous PTCA, complex lesions, diameter stenosis before
intervention, a lower balloon-to-vessel ratio, and multiple stent
placement. Figure 3 displays the relation
between vessel size and probability of restenosis for 2
arbitrarily assumed cutoff points of balloon-to-vessel ratio (0.90 and
1.10), adjusted for the effect of all other covariates in the model. A
lower risk for restenosis is expected for a balloon-to-vessel
ratio of 1.1 over the entire range of vessel sizes. The results of
CHAID analysis, illustrated in Figure 4, demonstrate that patients with small
vessels can be further divided into subgroups with different risks for
restenosis. A particularly high risk for restenosis is
associated with complex lesions in diabetic patients (53.5%). On the
other hand, almost 25% of patients with small vessels have a
combination of favorable characteristics (simple lesions, no diabetes)
that considerably reduces the risk of restenosis to
<30%. The subgroups with higher risk for restenosis (patients
with complex lesions or diabetes) did not differ significantly from
those with lower risk with respect to either vessel size
(P=0.5) or balloon-to-vessel ratio used during the procedure
(P=0.4).
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
This study indicates that patients with smaller vessel size have a less-favorable clinical outcome at 1 year after coronary stent placement than patients with larger vessels. Most of the difference in the 1-year clinical outcome was generated after the first month. In fact, patients with smaller vessels had very similar rates for the most adverse clinical events, ie, death and myocardial infarction. The difference in the overall event-free survival arose from a major need for revascularization procedures in patients with smaller vessels. This must be attributed to a restenosis rate for small vessels that was
1.5x higher than that demonstrated for
larger vessels. A worse clinical outcome was reported for subsets of
patients with small vessel size from the
BENESTENT9 and STRESS12
trials, especially when small vessel size was combined with greater
lesion length.18 Several studies failed to
demonstrate a significant independent role for vessel size in the
restenosis process.6 7 8 19 20 Although it
was part of the analysis, the relation between vessel size and
restenosis was not the principal focus of these studies, and
the limited number of patients in these studies may have imparted
insufficient power in this regard. Most of these studies entered
postprocedural MLD into the multivariate models, which
may have blunted the independent role of vessel size in outcome.
Recently, Serruys et al21 demonstrated that a
multivariate model based on vessel size and residual
stenosis (similar to our model) was more powerful than that
based on postprocedural MLD. This model is even more appropriate for
studies that are focused on the influence of vessel size. Our
angiographic findings are in line with those previously reported by
Foley et al5 in a large study with PTCA.
Although it is evident from the present study that a higher
incidence of restenosis is responsible for the more adverse
clinical outcome of patients with smaller vessels, the reason smaller
vessels carry a higher risk for restenosis is not clear. The
explanation must be sought in our results relative to late lumen loss.
We found similar values of late lumen loss in all 3 vessel-size groups
despite the significantly different acute gain achieved. Similar
findings have also emerged from studies with
PTCA.19 22 It is obvious that the same lumen loss
entails many more consequences for small vessels than for larger
vessels. A greater balloon-to-vessel ratio was used in the small-vessel
group, which may have led to greater vessel wall injury and more
considerable reactive neointimal
hyperplasia.23 However, it is difficult to accept
this as a mechanism for more restenosis in the small-vessel
group. Our multivariate model of restenosis
demonstrated that the adjusted risk for restenosis decreases if
a greater balloon-to-vessel ratio is used during the intervention
(Figure 4). The influence of balloon-to-vessel ratio on the risk for
early adverse events must be specifically assessed before the strategy
of using oversized balloons is recommended as a remedy for the
excessive restenosis verified in the group with small vessels.
Another mechanism of greater lumen loss in small vessels has recently been suggested by studies with intravascular ultrasound. Hoffmann et al24 found that preinterventional plaque burden, measured with intravascular ultrasound as the ratio between plaque and total artery area, was a very strong predictor of restenosis. Plaque burden is expected to be greater in smaller vessels, thereby representing more stimulus for lumen renarrowing. This may be particularly true for patients with diabetes.25 Other plausible explanations may come from differences in accompanying characteristics that may favor more restenosis in the small-vessel group. We found significant differences in age, sex distribution, frequency of diabetes, and proportion of lesions located in the left anterior descending coronary artery. In particular, a major presence of diabetes and the location of lesions in the left anterior descending coronary artery have frequently been associated with a higher risk for restenosis.26 27 28
The stratification scheme produced by the specific analysis for
the small-vessel group has clinical implications. We found that the
unusually high risk for restenosis does not equally affect all
patients with small vessels. Particularly unfavorable results were
confined to 
10% of these patients who had both complex lesions and
diabetes. For almost 25% of the patients, an acceptable
restenosis rate is expected that is not different from the
usual incidence of this complication after stenting.
A major limitation of the present study is that the analysis was restricted to stent implantation, and no other interventional devices were used. Thus, the results of this study enable us to state that small vessels are associated with higher risk after stenting but do not provide any information about the most appropriate treatment in this setting. The lack of intravascular ultrasound assessment must be considered an additional limitation of the present study. Such assessment might have provided more insights into potential specific restenosis mechanisms present in small vessels.29
Conclusions
Patients with small vessels present a higher risk for an
adverse outcome during the 12 months after coronary stent
placement. This higher risk is generated by a major need for
target-lesion revascularizations because of a
higher incidence of restenosis in small vessels. However, the
unusually high risk for restenosis is confined to a small
percentage of patients who have concomitant risk factors such as
diabetes and complex lesions. If such adverse characteristics are not
present, stenting may be safely performed in patients with small
coronary vessels, and favorable long-term results are to be
expected.
|
Footnotes |
|---|
Reprint requests to Dr Adnan Kastrati, Deutsches Herzzentrum München, Lazarettstraße 36, 80636 München, Germany.
Received January 5, 1998; revision received May 19, 1998; accepted June 23, 1998.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1. Serruys PW, de 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, van den Heuvel P, Delcan J, Morel MA. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease: Benestent Study Group. N Engl J Med. 1994;331:489–495.
2.
Fischman DL, Leon MB, Baim DS, Schatz RA, Savage MP,
Penn I, Detre K, Veltri L, Ricci D, Nobuyoshi M, Cleman M, Heuser R,
Almond D, Teirstein PS, Fish RD, Colombo A, Brinker J, Moses J,
Shaknovich A, Hirshfeld J, Bailey S, Ellis S, Rake R, Goldberg S. A
randomized comparison of coronary-stent placement and balloon
angioplasty in the treatment of coronary artery disease: Stent
Restenosis Study Investigators. N Engl J
Med. 1994;331:496–501.
3. ACC Expert Consensus Document. Coronary artery stents. J Am Coll Cardiol. 1996;28:782–794.[Medline] [Order article via Infotrieve]
4. Hirshfeld JW, Schwartz SS, Jugo R, Macdonald RG, Goldberg S, Savage MP, Bass TA, Vetrovec G, Cowley M, Taussig AS, Withworth HB, Margolis JR, Hill JA, Pepine CJ. Restenosis after coronary angioplasty: a multivariate statistical model to relate lesion and procedural variables to restenosis. J Am Coll Cardiol. 1991;18:647–656.[Abstract]
5.
Foley DP, Melkert R, Serruys PW. Influence of
coronary vessel size on renarrowing process and late
angiographic outcome after successful balloon angioplasty.
Circulation. 1994;90:1239–1251.
6.
Strauss BH, Serruys PW, de Scheerder IK, Tijssen JG,
Bertrand ME, Puel J, Meier B, Kaufmann U, Stauffer JC, Rickards AF,
Sigwart U. Relative risk analysis of angiographic predictors of
restenosis within the coronary Wallstent.
Circulation. 1991;84:1636–1643.
7.
Kuntz RE, Safian RD, Carrozza JP, Fishman RF, Mansour
M, Baim DS. The importance of acute luminal diameter in determining
restenosis after coronary atherectomy or stenting.
Circulation. 1992;86:1827–1835.
8.
Ellis SG, Savage M, Fischman D, Baim DS, Leon M,
Goldberg S, Hirshfeld JW, Cleman MW, Teirstein PS, Walker C, Bailey S,
Buchbinder M, Topol EJ, Schatz RA. Restenosis after placement
of Palmaz-Schatz stents in native coronary arteries: initial
results of a multicenter experience. Circulation. 1992;86:1836–1844.
9. Keane D, Azar AJ, de Jaegere P, Rutsch W, de Bruyne B, Legrand V, Kiemeneij F, de Feyter P, van de Heuvel P, Ozaki Y, Morel M. Clinical and angiographic outcome of elective stent implantation in small coronary vessels: an analysis of the BENESTENT trial. Semin Intervent Cardiol. 1996;1:255–262.[Medline] [Order article via Infotrieve]
10. Akiyama T, Goldberg SL, Di Mario C, Reimers B, Ferraro M, Martini G, Colombo A. Stenting small vessels. Eur Heart J. 1997;18(suppl):381. Abstract.
11. Kastrati A, Schömig A, Elezi S, Schühlen H, Dirschinger J, Hadamitzky H, Wehinger A, Hausleiter J, Walter H, Neumann FJ. Predictive factors of restenosis after coronary stent placement. J Am Coll Cardiol. 1997;30:1428–1436.[Abstract]
12.
Savage MP, Fischman DL, Rake R, Leon MB, Schatz RA,
Penn I, Nobuyoshi M, Moses J, Hirshfeld J, Heuser R, Baim D, Cleman M,
Brinker J, Gebhardt S, Goldberg S. Efficacy of coronary
stenting versus balloon angioplasty in small coronary arteries:
Stent Restenosis Study (STRESS) Investigators. J Am
Coll Cardiol. 1998;31:307–311.
13. Kuntz RE, Gibson CM, Nobuyoshi M, Baim DS. Generalized model of restenosis after conventional balloon angioplasty, stenting and directional atherectomy. J Am Coll Cardiol. 1993;21:15–25.[Abstract]
14.
Kuntz RE, Baim DS. Defining coronary
restenosis: newer clinical and angiographic paradigms.
Circulation. 1993;88:1310–1323.
15.
Topol EJ, Nissen SE. Our preoccupation with
coronary luminology. Circulation. 1995;92:2333–2342.
16.
Schömig A, Neumann FJ, Kastrati A, Schühlen
H, Blasini R, Hadamitzky M, Walter H, Zitzmann-Roth E, 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.
17.
Ellis SG, Vandormael MG, Cowley MJ, DiSciascio G,
Deligonul U, Topol EJ, Bulle TM. Coronary morphologic and
clinical determinants of procedural outcome with angioplasty for
multivessel coronary disease: implications for patient
selection. Circulation. 1990;82:1193–1202.
18. Mehran R, Hong MK, Lansky AJ, Brennan J, Morgan K, Weaver T, Wu H, Pichard AD. Vessel size and lesion length influence late clinical outcomes after native coronary artery stent placement. J Am Coll Cardiol. 1997;29(suppl A):274A. Abstract.
19.
Rensing BJ, Hermans WRM, Vos J, Tijssen JGP, Rutsch W,
Danchin N, Heyndrickx GR, Mast EG, Wijns W, Serruys PW. Luminal
narrowing after percutaneous transluminal
coronary angioplasty: a study of clinical, procedural, and
lesional factors related to long-term angiographic outcome.
Circulation. 1993;88:975–985.
20.
Moussa I, Reimers B, Moses J, Di Mario C, Di Francesco
L, Ferraro M, Colombo A. Long-term angiographic and clinical outcome of
patients undergoing multivessel coronary stenting.
Circulation. 1997;96:3873–3879.
21. Serruys PW, Kootstra J, Melkert R, de Jaegere P, van den Brand M, Morek M. Periprocedural quantitative coronary angiography following Palmaz-Schatz stent implantation predicts restenosis rate at 6 months: result of a meta-analysis of BENESTENT-I, BENESTENT-II and MUSIC. J Am Coll Cardiol. 1998;31(suppl A):64A. Abstract.
22. Hermans WRM, Rensing BJ, Foley DP, Tijssen JGP, Rutsch W, Emanuelsson H, Danchin N, Wijns W, Chappuis F, Serruys PW. Patient, lesion, and procedural variables as risk factors for luminal re-narrowing after successful coronary angioplasty: a quantitative analysis in 653 patients with 778 lesions. J Cardiovasc Pharmacol. 1993;22(suppl 4):S45–S57.
23. Serruys PW, Foley DP, Kirkeeide RL, King SB III. Restenosis revisited: insights provided by quantitative coronary angiography. Am Heart J. 1993;126:1243–1267.[Medline] [Order article via Infotrieve]
24.
Hoffmann R, Mintz GS, Mehran R, Pichard AD, Kent KM,
Satler LF, Popma JJ, Wu H, Leon MB. Intravascular ultrasound predictors
of angiographic restenosis in lesions treated with
Palmaz-Schatz stents. J Am Coll Cardiol. 1998;31:43–49.
25.
Kornowski R, Mintz GS, Kent KM, Pichard AD, Satler LF,
Bucher TA, Hong MK, Popma JJ, Leon MB. Increased restenosis in
diabetes mellitus after coronary interventions is due to
exaggerated intimal hyperplasia: a serial intravascular ultrasound
study. Circulation. 1997;95:1366–1369.
26. Carrozza JJ, Kuntz RE, Levine MJ, Pomerantz RM, Fishman RF, Mansour M, Gibson CM, Senerchia CC, Diver DJ, Safian RD, Baim DS. Angiographic and clinical outcome of intracoronary stenting: immediate and long-term results from a large single-center experience. J Am Coll Cardiol. 1992;20:328–337.[Abstract]
27.
Carrozza JPJ, Kuntz RE, Fishman RF, Baim DS.
Restenosis after arterial injury caused by
coronary stenting in patients with diabetes mellitus. Ann
Intern Med. 1993;118:344–349.
28. Moscucci M, Piana RN, Kuntz RE, Kugelmass AD, Carrozza JP Jr, Senerchia C, Baim DS. Effect of prior coronary restenosis on the risk of subsequent restenosis after stent placement or directional atherectomy. Am J Cardiol. 1994;73:1147–1153.[Medline] [Order article via Infotrieve]
29. Dussaillant GR, Mintz GS, Pichard AD, Kent KM, Satler LF, Popma JJ, Wong SC, Leon MB. Small stent size and intimal hyperplasia contribute to restenosis: a volumetric intravascular ultrasound analysis. J Am Coll Cardiol. 1995;26:720–724.[Abstract]
This article has been cited by other articles:
 |
|
 |
|
  T. G. Nuhrenberg, N. Langwieser, J. B.K. Schwarz, Y. Hou, P. Frank, F. Sorge, S. Matschurat, S. Seidl, A. Kastrati, A. Schomig, et al. EMAP-II downregulation contributes to the beneficial effects of rapamycin after vascular injury Cardiovasc Res, February 1, 2008; 77(3): 580 - 589. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. O. Jensen, P. Thayssen, L. Thuesen, H. S. Hansen, J. F. Lassen, H. Kelbaek, A. Junker, K. N. Hansen, H. E. Boetker, L. R. Krusell, et al. Influence of a Pressure Gradient Distal to Implanted Bare-Metal Stent on In-Stent Restenosis After Percutaneous Coronary Intervention Circulation, December 11, 2007; 116(24): 2802 - 2808. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Togni, S. Eber, J. Widmer, M. Billinger, P. Wenaweser, S. Cook, R. Vogel, C. Seiler, F. R. Eberli, W. Maier, et al. Impact of Vessel Size on Outcome After Implantation of Sirolimus-Eluting and Paclitaxel-Eluting Stents: A Subgroup Analysis of the SIRTAX Trial J. Am. Coll. Cardiol., September 18, 2007; 50(12): 1123 - 1131. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Elezi, A. Dibra, J. Mehilli, J. Pache, R. Wessely, A. Schomig, and A. Kastrati Vessel Size and Outcome After Coronary Drug-Eluting Stent Placement: Results From a Large Cohort of Patients Treated With Sirolimus- or Paclitaxel-Eluting Stents J. Am. Coll. Cardiol., October 3, 2006; 48(7): 1304 - 1309. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Fajadet, W. Wijns, G.-J. Laarman, K.-H. Kuck, J. Ormiston, T. Munzel, J. J. Popma, P. J. Fitzgerald, R. Bonan, R. E. Kuntz, et al. Randomized, Double-Blind, Multicenter Study of the Endeavor Zotarolimus-Eluting Phosphorylcholine-Encapsulated Stent for Treatment of Native Coronary Artery Lesions: Clinical and Angiographic Results of the ENDEAVOR II Trial Circulation, August 22, 2006; 114(8): 798 - 806. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Kastrati, A. Dibra, J. Mehilli, S. Mayer, S. Pinieck, J. Pache, J. Dirschinger, and A. Schomig Predictive Factors of Restenosis After Coronary Implantation of Sirolimus- or Paclitaxel-Eluting Stents Circulation, May 16, 2006; 113(19): 2293 - 2300. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. C. Henry, M. M. Bonar, P. N. Kearns, H. Cui, M. M. Mutchler, M. V. Martin, A. R. Orsini, H. L. Elford, C. A. Bush, J. L. Zweier, et al. Inhibition of Ribonucleotide Reductase Reduces Neointimal Formation following Balloon Injury J. Pharmacol. Exp. Ther., July 1, 2005; 314(1): 70 - 76. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Pache, A. Dibra, J. Mehilli, J. Dirschinger, A. Schomig, and A. Kastrati Drug-eluting stents compared with thin-strut bare stents for the reduction of restenosis: a prospective, randomized trial Eur. Heart J., July 1, 2005; 26(13): 1262 - 1268. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Agostoni, G. G.L. Biondi-Zoccai, G. L. Gasparini, M. Anselmi, G. Morando, M. Turri, A. Abbate, E. P. McFadden, C. Vassanelli, P. Zardini, et al. Is bare-metal stenting superior to balloon angioplasty for small vessel coronary artery disease? Evidence from a meta-analysis of randomized trials Eur. Heart J., May 1, 2005; 26(9): 881 - 889. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P.-E. Falcoz, S. Chocron, C. Binquet, L. Stoica, D. Kaili, C. Quantin, and J.-P. Etievent Revascularization of the Right Coronary Artery: Grafting or Percutaneous Coronary Intervention? Ann. Thorac. Surg., April 1, 2005; 79(4): 1232 - 1239. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. H. Lee, D. H. Kim, B.-H. Lee, H. J. Kim, C. H. Choi, K. P. Park, D. S. Jung, S. Kim, and T. Y. Moon Preliminary Results of Endovascular Stent-Assisted Angioplasty for Symptomatic Middle Cerebral Artery Stenosis AJNR Am. J. Neuroradiol., January 1, 2005; 26(1): 166 - 174. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Ardissino, C. Cavallini, E. Bramucci, C. Indolfi, A. Marzocchi, A. Manari, G. Angeloni, G. Carosio, E. Bonizzoni, S. Colusso, et al. Sirolimus-Eluting vs Uncoated Stents for Prevention of Restenosis in Small Coronary Arteries: A Randomized Trial JAMA, December 8, 2004; 292(22): 2727 - 2734. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Norman, M. Le, C. Pearce, and K. Jamrozik Infrarenal Aortic Diameter Predicts All-Cause Mortality Arterioscler. Thromb. Vasc. Biol., July 1, 2004; 24(7): 1278 - 1282. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Moreno, C. Fernandez, F. Alfonso, R. Hernandez, M. J. Perez-Vizcayno, J. Escaned, M. Sabate, C. Banuelos, D. J. Angiolillo, L. Azcona, et al. Coronary stenting versus balloon angioplasty in small vessels: A meta-analysis from 11 randomized studies J. Am. Coll. Cardiol., June 2, 2004; 43(11): 1964 - 1972. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J K Kim, J Y Ahn, B H Lee, Y S Chung, S S Chung, O J Kim, W C Kim, and J Y Joo Elective stenting for symptomatic middle cerebral artery stenosis presenting as transient ischaemic deficits or stroke attacks: short term arteriographical and clinical outcome J. Neurol. Neurosurg. Psychiatry, June 1, 2004; 75(6): 847 - 851. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. A. Lemos, A. Hoye, D. Goedhart, C. A. Arampatzis, F. Saia, W. J. van der Giessen, E. McFadden, G. Sianos, P. C. Smits, S. H. Hofma, et al. Clinical, Angiographic, and Procedural Predictors of Angiographic Restenosis After Sirolimus-Eluting Stent Implantation in Complex Patients: An Evaluation From the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) Study Circulation, March 23, 2004; 109(11): 1366 - 1370. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Gershlick, I. De Scheerder, B. Chevalier, A. Stephens-Lloyd, E. Camenzind, C. Vrints, N. Reifart, L. Missault, J.-J. Goy, J. A. Brinker, et al. Inhibition of Restenosis With a Paclitaxel-Eluting, Polymer-Free Coronary Stent: The European evaLUation of pacliTaxel Eluting Stent (ELUTES) Trial Circulation, February 3, 2004; 109(4): 487 - 493. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
Y.-H. Chen, L.-Y. Chau, M.-W. Lin, L.-C. Chen, M.-H. Yo, J.-W. Chen, and S.-J. Lin Heme oxygenase-1 gene promotor microsatellite polymorphism is associated with angiographic restenosis after coronary stenting Eur. Heart J., January 1, 2004; 25(1): 39 - 47. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I. Iakovou, G. S. Mintz, G. Dangas, A. Abizaid, R. Mehran, Y. Kobayashi, A. J. Lansky, E. D. Aymong, E. Nikolsky, G. W. Stone, et al. Increased CK-MB release is a "trade-off" for optimal stent implantation: an intravascular ultrasound study J. Am. Coll. Cardiol., December 3, 2003; 42(11): 1900 - 1905. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. W. Moses, M. B. Leon, J. J. Popma, P. J. Fitzgerald, D. R. Holmes, C. O'Shaughnessy, R. P. Caputo, D. J. Kereiakes, D. O. Williams, P. S. Teirstein, et al. Sirolimus-Eluting Stents versus Standard Stents in Patients with Stenosis in a Native Coronary Artery N. Engl. J. Med., October 2, 2003; 349(14): 1315 - 1323. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. V. Dee and H. Samady Evolving Strategies for the Prevention and Treatment of Coronary Restenosis Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 2003; 7(3): 281 - 293. [Abstract] [PDF]
|
|
|
|
|
|
J. Mehilli, A. Kastrati, H. Bollwein, A. Dibra, H. Schuhlen, J. Dirschinger, and A. Schomig Gender and restenosis after coronary artery stenting Eur. Heart J., August 2, 2003; 24(16): 1523 - 1530. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Kwon, D. Choi, S.-H. Choi, Bon Kwon Koo, Y. Jang, W.-H. Shim, and S.-Y. Cho Coronary Stenting After Rotational Atherectomy in Diffuse Lesions of the Small Coronary Artery: Comparison with Balloon Angioplasty Before Stenting Angiology, July 1, 2003; 54(4): 423 - 431. [Abstract] [PDF]
|
|
|
|
|
|
M. Haude, T. F.M. Konorza, U. Kalnins, A. Erglis, K. Saunamaki, H. D. Glogar, E. Grube, R. Gil, A. Serra, H. G. Richardt, et al. Heparin-Coated Stent Placement for the Treatment of Stenoses in Small Coronary Arteries of Symptomatic Patients Circulation, March 11, 2003; 107(9): 1265 - 1270. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Prpic, P. S. Teirstein, J. P. Reilly, J. W. Moses, P. Tripuraneni, A. J. Lansky, J.-A. Giorgianni, S. Jani, S. C. Wong, R. D. Fish, et al. Long-Term Outcome of Patients Treated With Repeat Percutaneous Coronary Intervention After Failure of {gamma}-Brachytherapy for the Treatment of In-Stent Restenosis Circulation, October 29, 2002; 106(18): 2340 - 2345. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J.o. Hausleiter, A. Kastrati, J. Mehilli, H. Schuhlen, J.u. Pache, F. Dotzer, J. Dirschinger, and A. Schomig Predictive factors for early cardiac events and angiographic restenosis after coronary stent placement in small coronary arteries J. Am. Coll. Cardiol., September 4, 2002; 40(5): 882 - 889. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Briguori, C. Sarais, P. Pagnotta, F. Liistro, M. Montorfano, A. Chieffo, F. Sgura, N. Corvaja, R. Albiero, G. Stankovic, et al. In-stent restenosis in small coronary arteries: Impact of strut thickness J. Am. Coll. Cardiol., August 7, 2002; 40(3): 403 - 409. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Sakakibara, S. Goto, K. Eto, N. Tamura, T. Isshiki, and S. Handa Application of Ex Vivo Flow Chamber System for Assessment of Stent Thrombosis Arterioscler. Thromb. Vasc. Biol., August 1, 2002; 22(8): 1360 - 1364. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Haude and R. Erbel How big is small? Eur. Heart J., February 1, 2002; 23(3): 198 - 199. [Full Text] [PDF]
|
|
|
|
|
|
C. Briguori, J. Tobis, T. Nishida, M. Vaghetti, R. Albiero, C. Di Mario, and A. Colombo Discrepancy between angiography and intravascular ultrasound when analysing small coronary arteries Eur. Heart J., February 1, 2002; 23(3): 247 - 254. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. C. Lowe, S. N. Oesterle, and L. M. Khachigian Coronary in-stent restenosis: Current status and future strategies J. Am. Coll. Cardiol., January 16, 2002; 39(2): 183 - 193. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Erdmann Cardiovascular events in patients with type 2 diabetes The British Journal of Diabetes & Vascular Disease, January 1, 2002; 2(1_suppl): S4 - S8. [Abstract] [PDF]
|
|
|
|
|
|
A. Kastrati, H. Schuhlen, and A. Schomig Stenting for small coronary vessels: a contestable winner J. Am. Coll. Cardiol., November 15, 2001; 38(6): 1604 - 1607. [Full Text] [PDF]
|
|
|
|
|
|
B.J Rensing, J Vos, P.C Smits, D.P Foley, M.J.B.M van den Brand, W.J van der Giessen, P.J de Feijter, and P.W Serruys Coronary restenosis elimination with a sirolimus eluting stent; First European human experience with 6-month angiographic and intravascular ultrasonic follow-up Eur. Heart J., November 2, 2001; 22(22): 2125 - 2130. [Abstract] [PDF]
|
|
|
|
|
|
S. Doucet, M. J. Schalij, M. C.M. Vrolix, D. Hilton, P. Chenu, B. de Bruyne, W. Udayachalerm, A. Seth, L. Bilodeau, J. H.C. Reiber, et al. Stent Placement to Prevent Restenosis After Angioplasty in Small Coronary Arteries Circulation, October 23, 2001; 104(17): 2029 - 2033. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Koning, H. Eltchaninoff, P. Commeau, K. Khalife, M. Gilard, J. Lipiecki, P. Coste, M. Bedossa, T. Lefevre, P. Brunel, et al. Stent Placement Compared With Balloon Angioplasty for Small Coronary Arteries: In-Hospital and 6-Month Clinical and Angiographic Results Circulation, October 2, 2001; 104(14): 1604 - 1608. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Mercado, E. Boersma, W. Wijns, B. J. Gersh, C. A. Morillo, V. de Valk, G.-A. van Es, D. E. Grobbee, and P. W. Serruys Clinical and quantitative coronary angiographic predictors of coronary restenosis: A comparative analysis from the balloon-to-stent era J. Am. Coll. Cardiol., September 1, 2001; 38(3): 645 - 652. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M.Y Salame, S Verheye, I.R Crocker, N.A.F Chronos, K.A Robinson, and S.B King III Intracoronary radiation therapy Eur. Heart J., April 2, 2001; 22(8): 629 - 647. [PDF]
|
|
|
|
 |
|
 U E Heidland, M P Heintzen, C J Michel, and B E Strauer Risk factors for the development of restenosis following stent implantation of venous bypass grafts Heart, March 1, 2001; 85(3): 312 - 317. [Abstract] [Full Text]
|
|
|
|
|
|
R. S. Kiesz, P. Buszman, J. L. Martin, E. Deutsch, M. M. Rozek, E. Gaszewska, M. Rewicki, P. Seweryniak, M. Kosmider, and M. Tendera Local Delivery of Enoxaparin to Decrease Restenosis After Stenting: Results of Initial Multicenter Trial : Polish-American Local Lovenox NIR Assessment Study (The POLONIA Study) Circulation, January 2, 2001; 103(1): 26 - 31. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Kastrati, A. Schomig, J. Dirschinger, J. Mehilli, F. Dotzer, N. von Welser, and F.-J. Neumann A Randomized Trial Comparing Stenting With Balloon Angioplasty in Small Vessels in Patients With Symptomatic Coronary Artery Disease Circulation, November 21, 2000; 102(21): 2593 - 2598. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Roguin and R. Beyar Small vessel stenting is safe, but still waiting for a well-proven antirestenotic effect Eur. Heart J., November 1, 2000; 21(21): 1732 - 1734. [PDF]
|
|
|
|
|
|
R. Hoffmann and G.S. Mintz Coronary in-stent restenosis--predictors, treatment and prevention Eur. Heart J., November 1, 2000; 21(21): 1739 - 1749. [PDF]
|
|
|
|
|
|
S.-W Park, C.W Lee, M.-K Hong, J.-J Kim, G.-Y Cho, D.-Y Nah, and S.-J Park Randomized comparison of coronary stenting with optimal balloon angioplasty for treatment of lesions in small coronary arteries Eur. Heart J., November 1, 2000; 21(21): 1785 - 1789. [Abstract] [PDF]
|
|
|
|
|
|
C Di Mario, F Marsico, M Adamian, E Karvouni, R Albiero, and A Colombo New recipes for in-stent restenosis: cut, grate, roast, or sandwich the neointima? Heart, November 1, 2000; 84(5): 471 - 475. [Full Text]
|
|
|
|
|
|
J. Al Suwaidi, P. B. Berger, and D. R. Holmes Jr Coronary Artery Stents JAMA, October 11, 2000; 284(14): 1828 - 1836. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P K Haager, E R Schwarz, J v. Dahl, H G Klues, T Reffelmann, and P Hanrath Long term angiographic and clinical follow up in patients with stent implantation for symptomatic myocardial bridging Heart, October 1, 2000; 84(4): 403 - 408. [Abstract] [Full Text]
|
|
|
|
|
|
C M Gross, J Kramer, O Weingartner, F Uhlich, R Dietz, and J Waigand Clinical and angiographic outcome in patients with in-stent restenosis and repeat target lesion revascularisation in small coronary arteries Heart, September 1, 2000; 84(3): 307 - 313. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Koster, J. Kahler, W. Terres, J. Reimers, S. Baldus, D. Hartig, J.u. Berger, T. Meinertz, and C. W. Hamm Six-month clinical and angiographic outcome after successful excimer laser angioplasty for in-stent restenosis J. Am. Coll. Cardiol., July 1, 2000; 36(1): 69 - 74. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Gyongyosi, P. Yang, A. Khorsand, D. Glogar, on behalf of the Austrian Wiktor Stent Study Group, and European Paragon Stent Investigators Longitudinal straightening effect of stents is an additional predictor for major adverse cardiac events J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1580 - 1589. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Ishiwata, S. Verheye, K. A. Robinson, M. Y. Salame, H. de Leon, S. B. King III, and N. A. F. Chronos Inhibition of neointima formation by tranilast in pig coronary arteries after balloon angioplasty and stent implantation J. Am. Coll. Cardiol., April 1, 2000; 35(5): 1331 - 1337. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Y. Salame, S. Verheye, S. P. Mulkey, N. A. F. Chronos, S. B. King III, I. R. Crocker, and K. A. Robinson The Effect of Endovascular Irradiation on Platelet Recruitment at Sites of Balloon Angioplasty in Pig Coronary Arteries Circulation, March 14, 2000; 101(10): 1087 - 1090. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. Haller and W. Kubler The disappointing results of PTCA in the uraemic patientare stents the answer? Nephrol. Dial. Transplant., November 1, 1999; 14(11): 2582 - 2584. [Full Text] [PDF]
|
|
|
|
 |
|
 R. W. Emery, K. V. Arom, T. F. Flavin, and A. M. Emery A case for minimally invasive coronary surgery as primary treatment for left anterior descending coronary artery disease Eur. J. Cardiothorac. Surg., November 1, 1999; 16(suppl_2): S112 - S116. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. J. de Feyter, P. Kay, C. Disco, and P. W. Serruys Reference Chart Derived From Post-Stent-Implantation Intravascular Ultrasound Predictors of 6-Month Expected Restenosis on Quantitative Coronary Angiography Circulation, October 26, 1999; 100(17): 1777 - 1783. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. E. Chambers, S. T Riebel, and M. Kozak Interventional Cardiology: Advances in Percutaneous Techniques for the Treatment of Cardiac Disease Seminars in Cardiothoracic and Vascular Anesthesia, July 1, 1999; 3(2): 109 - 125. [Abstract] [PDF]
|
|
|
|
 |
|
 M. J. Sierevogel, E. Velema, P. P. de Jaegere, D. P. de Kleijn, C. Borst, and G. Pasterkamp Minimal Duration of Oral Matrix Metalloproteinase Inhibition to Prevent Constrictive Arterial Remodeling after Balloon Dilation in the Pig Radiology, February 1, 2002; 222(2): 468 - 473. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||