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Outcomes of Second Revascularization Procedures after Stent Implantation

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Abstract

Drug-eluting stents (DES) reduce subsequent revascularization procedures. Although randomized trials have compared DES to brachytherapy and balloon angioplasty (PTCA) for in-stent restenosis, few long-term comparisons have been made to bare metal stents (BMS) or bypass surgery (CABG), particularly following second procedures. We sought to assess the association between revascularization modality and long-term clinical outcomes of patients receiving a second procedure for coronary artery disease. Between January 2000 and July 2005, 4,666 consecutive patients underwent initial coronary stent implantation (DES or BMS). From this population we identified 569 patients undergoing a second target vessel revascularization (DES, BMS, PTCA or CABG). Outcomes were assessed at 6, 12, and 24 months after the second procedure, with follow-up through September 2006. Adjusted cumulative incidence rates were calculated using inverse probability weighted estimators. We found that at 24 months, there were no significant differences in death or myocardial infarction for PTCA, BMS, DES, and CABG (17.7%, 14.9%, 7.5%, and 10.2%, p = 0.26[3df]). DES patients had lower rates of death or myocardial infarction or third target vessel procedures than patients receiving PTCA (14.6% vs. 30.0%, p = 0.01) and BMS (14.6% vs. 42.2%, p < 0.01), but rates similar to CABG patients (14.6% vs. 14.6%, p = 0.99). For patients undergoing a second revascularization procedure, PTCA, BMS, DES, and CABG are associated with a similar risk of death or non-fatal myocardial infarction. DES and CABG are associated with lower rates of third revascularization procedures compared to PTCA and BMS. Further studies are needed to determine the optimum application for CABG vs. DES as a second or third revascularization procedure.

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Abbreviations

BMS:

Bare metal stent

CABG:

Coronary artery bypass grafting

DES:

Drug-eluting stent

DF:

Degrees of freedom

MI:

Myocardial infarction

PTCA:

Balloon angioplasty

TVR:

Target vessel revascularization

TVR3:

Third target vessel revascularization

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Acknowledgments

We thank Maqui Ortiz, Duke Clinical Research Institute, for her expert editing of these materials and Elise Berliner, PhD, Agency for Healthcare Research and Quality for her advocacy for the Treatment of In-Stent Restenosis project and for her feedback during its execution.

This project was funded under Contract No. 290-05-0032 from the Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, MD as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the US Department of Health and Human Services. Based on the AHRQ DEcIDE report titled “Treatment of In-Stent Restenosis” (AHRQ Publication, under review).

Conflict of Interest

Dr. Konstance, Dr. Kong, Ms. Shaw, and Dr. Matchar did not report any conflicts of interest. Dr. Eisenstein reported receiving research grants from Medtronic Vascular. Dr. Anstrom reported receiving research support from National Institutes of Health / National Heart, Lung, and Blood Institute, the Agency for Healthcare Research and Quality, Proctor and Gamble, Pfizer, Medtronic, Alexion Pharmaceuticals, Medicure, Medtronic Vascular, Bristol-Myers Squibb, and Novartis Pharmaceuticals. Dr. Califf reported receiving grants or contracts from Abbott Vascular Devices, Advanced Cardiovascular Systems, Advanced Stent Technologies, Boston Scientific, Bristol-Myers Squibb, Conor Medsystems Inc., Cordis Corporation, Guidant Corporation, Medtronic, Sanofi-Aventis, and Terumo Medical Corporation. Dr. Harrington reported receiving research grants from Boston Scientific, Cordis Corporation, Medtronic, Conor Medsystems Inc, Bristol-Myers Squibb, and Sanofi-Aventis; and performs consulting work for Bristol-Myers Squibb and Sanofi-Aventis. Dr. Schulman reported research support from Bristol-Myers Squibb Company and Johnson & Johnson; and he has served as a consultant for Sanofi-Aventis US LLC and Boston Scientific Corporation.

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Authors and Affiliations

  1. Department of Medicine, Duke University Medical Center, Durham, NC, USA

    Richard P. Konstance, Eric L. Eisenstein, Robert M. Califf, Robert A. Harrington, David B. Matchar, Kevin A. Schulman & David F. Kong

  2. Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA

    Kevin J. Anstrom

  3. Duke Clinical Research Institute, DUMC Box 3865, Durham, NC, 27710, USA

    Richard P. Konstance, Eric L. Eisenstein, Kevin J. Anstrom, Linda K. Shaw, Robert M. Califf, Robert A. Harrington, Kevin A. Schulman & David F. Kong

  4. Duke Translational Medicine Institute, Durham, NC, USA

    Richard P. Konstance, Eric L. Eisenstein, Kevin J. Anstrom, Linda K. Shaw, Robert M. Califf, Robert A. Harrington, David B. Matchar, Kevin A. Schulman & David F. Kong

  5. Duke Center for Clinical Health Policy Research, Durham, NC, USA

    David B. Matchar

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  1. Richard P. Konstance
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  2. Eric L. Eisenstein
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  9. David F. Kong
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Correspondence to Eric L. Eisenstein.

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Konstance, R.P., Eisenstein, E.L., Anstrom, K.J. et al. Outcomes of Second Revascularization Procedures after Stent Implantation. J Med Syst 32, 177–186 (2008). https://doi.org/10.1007/s10916-007-9120-x

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