With Newer-Generation DES, Ultralong Stenting Tied to Adverse Events

Patients receiving newer-generation DES at lengths exceeding 50 mm are at higher risk of TLR and MACE, according to an observational study published online May 23, 2015, ahead of print in Catheterization and Cardiovascular Interventions.

The Take Home:  With Newer-Generation DES

But shorter DES lengths are “safe and acceptable,” say Yohsuke Honda, MD, of Saiseikai Yokohama City Eastern Hospital (Yokohama City, Japan), and colleagues.

The researchers reviewed data on 1,669 consecutive patients (mean age 70 years; 74.5% men) with 2,763 lesions who received PCI at their center between 2009 and 2013. Patients were classified according to whether stented lengths were short (< 20 mm; n = 745), long (20-50 mm; n = 758), or ultralong (> 50 mm; n = 166).

Stent types included:

  • Xience V, Xience Prime, and Xience Expedition (Abbott Vascular)
  • Promus, Promus Element, and Promus Premier (Boston Scientific)
  • Nobori (Terumo)
  • Resolute Integrity (Medtronic)

Baseline characteristics—including coronary risk factors—were well-matched among the 3 groups. Compared with short and long DES, ultralong DES implantation was less common in lesions that were bifurcated (P < .001) or had in-stent restenosis (P = .002) and more common in chronic total occlusions (P < .001).

All patients took aspirin and clopidogrel prior to PCI, and dual antiplatelet therapy was scheduled for at least 1 year following DES implantation.

Increases in TLR, MACE

After a mean follow-up of 23.1 months, rates of TLR (primary endpoint) and MACE (composite of TLR, stent thrombosis, and cardiac death) were higher among those who received ultralong compared with short and long DES (table 1).

Table 1.  Outcomes at Mean Follow-up of 23.1 Months by DES Length

Kaplan-Meier analysis also showed a similar incidence of Bleeding Academic Research Consortium-defined major bleeding after stenting across short (8.1%), long (8.2%), and ultralong (5.8%) groups (log-rank P = .83).

On multivariate analysis, stent length exceeding 50 mm emerged as a predictor of TLR (RR 1.67; 95% CI 1.07-2.55), as did hemodialysis (RR 2.53; 95% CI 1.69-3.67).

Ultralong DES were not associated with higher risk of stent thrombosis, though the researchers acknowledge that their small sample size could have limited its ability to detect a difference.

Results Described as ‘Quite Good’

Given the increased rates of TLR and MACE with lengths beyond 50 mm, the researchers conclude that clinicians “should avoid ultralong [second-generation] DES implantation if possible especially in patients with hemodialysis.”

But Jeffrey W. Moses, MD, of Columbia University Medical Center/Weill Cornell Medical Center (New York, NY), disagreed with this advice in a telephone interview with TCTMD.

While the need for TLR does increase with longer DES, he said, the rates observed in the study are acceptable given the low mortality over the 4-year period. “The overall performance is quite good,” Dr. Moses said, adding that the “encouraging” results for ultralong DES may mean that the strategy is an option for the rising number of chronic total occlusions.

The safety of ultralong DES may ultimately depend on the skills of individual clinicians, Stephen G. Ellis, MD, of Cleveland Clinic (Cleveland, OH), told TCTMD in an email. “With good technique, one can get pretty good results with good DES, even if lesions are very long,” he noted.

Additionally, “good antiplatelet prescription appears to be our best ‘defense’ in these cases,” Dr. Ellis said, adding that “CABG should be recommended for patients with high SYNTAX or anticipated high residual SYNTAX scores.”He cautioned, however, that the study had several unusual aspects, including IVUS guidance for 98% of lesions treated and the inability to rule out a difference in stent thrombosis. Importantly, he stressed, the paper suggests that the researchers “did not do the appropriate statistical test to show 50 mm is a good cutoff” for predicting outcomes.

Nicole Lou is the 2015 Recipient of the Jason Kahn Fellowship in Medical Journalism 

  • Honda Y, Muramatsu T, Ito Y, et al. Impact of ultralong second-generation drug-eluting stent implantation. Cath and Cardiovasc Interv. 2015;Epub ahead of print.

  • Dr. Honda reports no relevant conflicts of interest.
  • Dr. Moses reports serving as a consultant for Abbott Vascular and Boston Scientific.
  • Dr. Ellis reports serving as a consultant for Abbott Vascular, Boston Scientific, and Medtronic.