Deteriorative effect of smoking on target lesion revascularization after implantation of coronary stents with diameter of 3.0 mm or less.
ABSTRACT Although smoking cessation is widely encouraged because of the associated risk of cardiovascular events, the impact of smoking on target lesion revascularization (TLR) after percutaneous coronary intervention (PCI) is controversial. Therefore, the present study retrospectively investigated the effect of smoking on TLR after plain-old balloon angioplasty (POBA; n=376) and stenting (STENT; n=434) in patients undergoing secondary coronary angiography at a single center.
A smoker was defined as current smoking or quitting within 2 years of the first PCI. In the POBA group, the predictors for TLR, as calculated by multiple logistic regression analysis, were a complex type of lesion (p<0.0001) and the left anterior descending artery (LAD) as affected vessel (p<0.05). In the STENT group, the predictors were the final % diameter of stenosis after stenting, measured by quantitative coronary arteriography (p<0.0005), LAD (p<0.01), and smoking (p=0.049). When the STENT group was divided into 2 groups according to the diameter of the implanted stent, smoking was a predictive factors for TLR in the group that received relatively small stents (diameter < or =3.0 mm) (p<0.02), but not in the group that received larger stents (diameter > or =3.5 mm).
Smoking has a deteriorative effect on TLR after implantation of relatively small coronary stents with a diameter of 3.0 mm or less.
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ABSTRACT: To identify possible biological risk factors for restenosis following successful percutaneous transluminal coronary angioplasty (PTCA) in patients having single or multivessel disease. The effect of continued smoking on restenosis was also evaluated. In this prospective smoking controlled study all subjects had a routine angiographic restudy after 6 months. The biological risk factors assessed before angioplasty were adrenaline, endothelin, fibrinogen, lipoprotein (a) and tissue plasminogen activator. The study population consisted of 122 patients of whom 25% were current smokers. Angiographic restenosis was defined as at least 50% diameter stenosis on the follow-up angiogram after an initially successful procedure. Restenosis was observed in 43% of patients. The restenosis rate was significantly lower among current smokers, but they were significantly younger and also had significantly less dilated stenoses. Multivariate analysis revealed the number of dilated stenoses, the mean inflation time, post-PTCA percentage diameter stenosis and left anterior descending coronary artery to be predictive of restenosis, while continued smoking was not. When only the lesion with the greatest loss in luminal diameter of each patient was considered, the multiple linear regression analysis revealed high endothelin level to be predictive of restenosis. This study revealed high endothelin levels to be predictive of luminal narrowing after angioplasty. In addition, the number of dilated stenoses, the mean inflation time, post-PTCA percentage diameter stenosis and stenosis location in the left anterior descending artery were found to be predictive of restenosis. However, continued smoking after angioplasty did not emerge as a risk factor for restenosis.Journal of Internal Medicine 12/1996; 240(5):293-301. · 6.46 Impact Factor
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ABSTRACT: uring the past 20 years, the equipment used to perform percutaneous coronary revascularization has undergone a dramatic transformation from simple balloon dilatation catheters to sophisticated mechanical devices and endopros- theses. The impetus for this evolution in technology was initially a byproduct of suboptimal immediate and long-term results obtained with standard balloon angioplasty. New techniques, including directional and rotational atherectomy, have resulted in improved procedural success rates, especially for more complex lesion subtypes, although their ability to curtail restenosis remains controversial. 1,2 Intracoronary stents have had a dramatic impact on reduction of the incidence of acute complications after failed balloon angio- plasty and represent the only currently available strategy shown to limit both clinical and angiographic restenosis. 3-12 Based on these advantages, stent implantation is used in approximately half of all percutaneous interventions in the United States. However, despite their proven benefits, coro- nary stents continue to be accompanied by several theoretical and practical limitations: they are costly, typically associated with a more marked degree of neointimal formation than balloon angioplasty, and difficult to use with some lesion subsets such as bifurcation stenoses, and they have engen- dered the new and difficult-to-treat entity of in-stent restenosis. Although the major focus in the field of interventional cardiology over the past decade has been on the development of new devices and adjunctive pharmacological therapies, the short- and long-term success rates after standard balloon angioplasty have improved significantly. Part of the improve- ment is likely a manifestation of enhanced operator experi- ence and better equipment, but the results of balloon angio- plasty have also benefited greatly from the availability of coronary stents for both "bailout" (for actual or threatened abrupt closure) or "backup" (for suboptimal balloon results) indications, potentially allowing a strategy of more aggres- sive balloon dilatation than could be safely performed in the pre-stent era. This report details the forces that resulted in the shift from reliance on balloon angioplasty as the primary mode of therapy for the majority of percutaneous interven- tions and, with the use of data from several recent clinical trials, will provide the rationale for a potential return to the use of balloon angioplasty (with provisional stent placement) as the predominant means of coronary revascularization. Balloon Angioplasty: Historical Experience Balloon dilatation, by virtue of barotrauma to the vessel wall, has long been recognized as a technique with a certain degree of unpredictability. Necropsy studies of coronary segments in the hours to days after successful balloon angioplasty in patients who died from cardiac and noncardiac causes dem- onstrate the near-universal presence of intimal tears at the site of dilatation with variable degrees of associated medial penetration, ranging from minimal intimal disruption to extensive dissection during angioplasty with concomitant vessel closure.13 Although major dissection and abrupt vessel closure have been associated with certain angiographic fea- tures (including proximal vessel tortuosity, lesion eccentric- ity, length, and angulation), these potentially catastrophic events tend to be difficult to predict for any individual patient.14,15 Abrupt closure resulting from balloon angioplasty occurred in 4.5% of the 1155 patients enrolled in the initial NHLBI registry between 1979 and 1981.16 Among those with periprocedural vessel occlusion, 41% had a myocardial in- farction and 72% required bypass surgery, and the overall mortality rate was 4.9%. Despite improved experience with the procedure, the incidence of abrupt closure after balloon dilatation in the late 1980s and early 1990s remained in the range of 4% to 8%, with .20% of these patients requiring an emergency bypass operation despite the use of longer infla- tions and perfusion devices.17,18 Apart from acute complications, balloon angioplasty as performed in the 1980s was associated with the frequent occurrence of angiographic and clinical restenosis. The bi- nary restenosis rates reported for the placebo arms in 28 large (study population of .100) prospective trials of adjunctive pharmacological therapy after balloon angioplasty published between 1985 and 1993 varied from 19% to 63%, with the majority falling in the 30% to 50% range.19 The need for target lesion revascularization during 6-month follow-up generally ranged from 20% to 30%. Despite evidence indi- cating that restenosis rates are inversely proportional to postprocedural luminal diameter,20 the unpredictable response of the lesion site to balloon dilatation coupled with the significant morbidity and mortality rates associated withCirculation 05/1998; 97(13):1298-305. · 15.20 Impact Factor
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ABSTRACT: We sought to evaluate clinical restenosis in a large population of patients who had undergone coronary stent placement. One-year success after coronary stenting is limited mainly by restenosis of and requirement for repeat revascularization of the treated lesion. We studied 6,186 patients (6,219 lesions) pooled from several recently completed coronary stent trials. Clinical restenosis was defined using three different definitions: target lesion revascularization (TLR) beyond 30 days, target vessel revascularization (TVR) beyond 30 days, and target vessel failure (TVF), defined as TVR, any death, or myocardial infarction (MI) of the target vessel territory after hospital discharge. By one year, 638 (12.2%) patients had TLR, 748 (14.3%) had TVR, and 848 (16.0%) had TVF, more than two-thirds higher than the rate of these end points at six months. The severity of angiographic restenosis (> or =50% follow-up diameter stenosis [DS]) in 419 of 1,437 (29%) patients undergoing routine angiographic follow-up correlated directly with the likelihood of TLR (73% vs. 26% for >70% DS compared with <60% DS). Smaller pretreatment minimum lumen diameter (MLD), smaller final MLD, longer stent length, diabetes mellitus, unstable angina, and hypertension were independent predictors of TLR. Prior MI and current smoking were negative predictors. At one year after stenting, most clinical restenosis reflected TLR, which was predicted by the same variables previously associated with an increased risk of angiographic restenosis. The lower absolute rate of clinical restenosis relative to angiographic restenosis was due to infrequent TLR in lesions with less severe (<60% DS) angiographic renarrowing.Journal of the American College of Cardiology 12/2002; 40(12):2082-9. · 14.09 Impact Factor