September 13, 2006Journal of the American College of Cardiology
Vessel Size and Outcome After Coronary Drug-Eluting Stent Placement
Key result
SES linked to ~48% lower TLR versus PES in small coronary vessels.
- P=0.02
- n=2,058
Why the study?
Dedicated studies examining the influence of vessel size on outcomes in patients treated with different drug-eluting stents were lacking.
Does vessel size influence target lesion revascularization rates in patients receiving sirolimus-eluting or paclitaxel-eluting stents?
Key Points
- The aim was to assess how vessel size affects outcomes after drug-eluting stent placement in patients.
- Analyzed 2,058 patients receiving sirolimus-eluting or paclitaxel-eluting stents.
- Grouped patients based on vessel size into three tertiles.
- Primary endpoint was target lesion revascularization; secondary endpoints included binary angiographic restenosis and composite death or myocardial infarction.
- Lower tertile had higher TLR rates (12.1%) compared to middle (8.4%) and upper (8.0%) tertiles (p=0.02).
- Vessel size was an independent predictor of TLR (p=0.009).
- Significant interaction between DES type and vessel size regarding TLR (p=0.008), with SESs outperforming PESs in smaller vessels.
Study Design
Type
Cohort (n=2,058)
Structured PICO
Does vessel size influence target lesion revascularization rates in patients receiving sirolimus-eluting or paclitaxel-eluting stents?
P
Population
2,058 consecutive patients who received sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES)
I
Intervention
Sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) implantation
C
Comparator
Comparison across vessel size tertiles (<2.41 mm, 2.41 to 2.84 mm, and >2.84 mm) and between stent types (SES vs PES)
O
Outcome
Target lesion revascularization (TLR)hard clinical
Main Result
Absolute Event Rate: 12.1% vs 8.4%
p-value: p=0.02
Sirolimus-eluting stents provide better outcomes than paclitaxel-eluting stents in small coronary vessels, where smaller vessel size is an independent predictor of target lesion revascularization.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Composite medical devices with a wide range of structural, geometric and pharmacological differences can be shown to produce different clinical effects as the environments in which they are tested become increasingly complex.”
“This trial and editorial add powerful new information to our understanding of the differences between the CYPHER Stent and the Taxus Stent. To date, there have been 11 randomized clinical trials and three meta analyses -- the highest levels of clinical evidence -- comparing the two drug-eluting stents. With each meta-analysis, the CYPHER Stent outperformed the Taxus Stent in key performance parameters. Today's analysis by Dr. Kastrati and the editorial by Drs. Rogers and Edelman provide further critical insights into these differences.”
GSGeorge SiontisCardiologist, University Hospital Bern
“In a large real-world cohort of patients treated with a stent, small-vessel diameter was identified as the most powerful predictor of restenosis.”
Implication
Small-vessel PCI with first-generation DES carries higher TLR risk; leaves open whether SES superiority over PES persists with newer platforms.
Abstract
OBJECTIVES: This study sought to investigate the influence of vessel size on the outcomes of patients after drug-eluting stent (DES) implantation. BACKGROUND: There are no dedicated studies on the influence of vessel size on the outcomes of patients treated with different DES. METHODS: The study population was composed of 2,058 consecutive patients who received sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES). Patients were grouped into tertiles according to vessel size (<2.41 mm in the lower tertile, 2.41 to 2.84 mm in the middle tertile, and >2.84 mm in the upper tertile). The primary end point was target lesion revascularization (TLR). Secondary end points were binary angiographic restenosis and the composite of death or myocardial infarction. RESULTS: Vessel size did not influence the composite end point of death and myocardial infarction. The TLR rates were higher among patients in the lower tertile (12.1%) as compared with the middle (8.4%) and upper (8.0%) tertiles (p = 0.02). In a multivariate analysis, vessel size emerged an independent predictor of TLR (p = 0.009). The model showed also a significant interaction between DES type and vessel size regarding TLR (p = 0.008). There was a significant difference in TLR rates among patients treated with SESs (8.6%) and PESs (16.4%) in the lower tertile (p = 0.002), but not in the middle and upper tertiles. CONCLUSIONS: The influence of vessel size on restenosis is related to the specific DES used, with SESs providing better outcomes than PESs in small but not in large coronary vessels.
Discussion
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Cite This Study
Elezi et al. (2006) conducted a cohort in Coronary artery disease requiring drug-eluting stent (n=2,058). Sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) vs. Vessel size tertiles was evaluated on Target lesion revascularization (TLR) (p=0.02). Small coronary vessel size (<2.41 mm) increased target lesion revascularization (12.1% vs 8.4% and 8.0%, p=0.02), with sirolimus stents outperforming paclitaxel stents (8.6% vs 16.4%, p=0.002).