Abstract
Background
Stent thrombosis (ST) and restenosis are concerns after percutaneous coronary intervention (PCI). Limited information exists concerning clinical and angiographic outcomes following multiple stent insertion. We therefore present the long-term outcome from drug-eluting stent (DES) insertion and correlate this with the Syntax score.
Methods and Results
Between April 2002 and 2006, all patients that underwent multilesion PCI (defined as ≥4 DES) were included for analysis, and follow-up commenced from the point where the fourth stent was inserted. Three hundred and seventy-four patients were identified, comprising 1972 lesions; 99% had clinical (30±16 months), and 72% had angiographic follow-up. The mean number of stents implanted was 5.7±1.9 and with length of 137±50 mm and Syntax Score of 24±8. The Syntax score (SS) did not predict major adverse cardiac events (MACE) at long-term follow-up, which occurred in 33% in the low SS (<22), 34% intermediate SS (22–32) and 40% in the high SS (>33); P =ns. However, the number of stents implanted correlated with events [MACE: 12% (4 DES), 35% (4–6 DES), 61% (>6 DES)]. There were 11 (2.9%) definite and probable ST: four acute and subacute, three late, and four very late.
Conclusions
This study demonstrates an acceptable occurrence of myocardial infarction, death, repeat revascularisation, and ST in patients with multivessel de novo lesions, which had better correlation with the number of DES inserted than the Syntax score.
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Introduction
The approach to the treatment of multivessel coronary disease (MVD) has evolved significantly in recent years . Several observational and randomised studies have shown equivalence between percutaneous and surgical revascularisation . These findings in conjunction with randomised trials demonstrating less neointimal proliferation with drug-eluting stents (DES) compared to bare metal equivalents (BMS) has encouraged more liberal use of DES by operators in long and complex coronary lesions . This practice occurred despite the pivotal trials enrolling a small percentage of patients with 2–3-vessel disease with only one lesion treated with up to 2 stents per patient. The so-called off-label use of these stents has resulted in conflicting reports as to the safety of these devices in lesions involving bifurcations , chronic total occlusions, in-stent restenosis, and the left main stem . Furthermore, recent concerns of DES safety with regard to stent thrombosis (ST) has resulted in changes to guidelines and the risk of ST after multiple DES implantation with current interventional practice is still unknown . The recently reported follow-up from the randomised SYNTAX study (Taxus Drug Eluting Stent versus Coronary Artery Bypass Surgery For the Treatment of Narrowed Arteries) , which enrolled patients with multivessel disease and left main stem stenosis, demonstrated equivalence between percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) in terms of its composite primary end point of major adverse cardiac and cerebrovascular events (MACCE). The inevitable risk attributable to the discontinuation of clopidogrel after 1 year of implantation adds further concerns. To date, few studies have addressed these issues in MVD; we therefore conducted a retrospective observational study investigating the long-term impact of multiple DES implantation (defined as ≥4 DES) in relation to Syntax score on clinical and angiographic outcomes.
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