RIBS III: Alternative DES Best Bet for DES In-Stent Restenosis
SAN FRANCISCO, CA—The best strategy for treating DES in-stent restenosis is implantation of a different type of DES, according to results of the prospective, multicenter RIBS-III trial. The findings were presented by Fernando Alfonso, MD, PhD, of Clinico San Carlos University Hospital (Madrid, Spain) November 8, 2011, at the annual Transcatheter Cardiovascular Therapeutics scientific symposium.
Among a cohort of 363 patients with DES in-stent restenosis, 325 were treated with repeat DES. Outcomes were compared for the 75% of patients who received a different type of DES in the second procedure (different-DES group) vs. the 25% who received the same type (same-DES group).
Baseline clinical characteristics were similar for the 2 groups, with diabetics constituting about half of each arm. However, there was a trend toward a shorter time to in-stent restenosis in the different-DES group (279 days vs. 334 days; P = 0.07), indicating more aggressive disease. Lesion locations were evenly distributed between different-DES and same-DES groups.
Different-DES Improve Angiographic Outcomes
Quantitative coronary angiography assessment of 275 patients showed that in-segment minimal lumen diameter (MLD), the primary angiographic endpoint, was larger in the different-DES group than the same-DES group (1.86 mm vs. 1.40 mm; P = 0.003), as was in-lesion MLD (1.69 mm vs. 1.54 mm; P = 0.01). Several other angiographic parameters also favored the different-DES strategy, including late lumen loss (0.42 mm vs. 0.63 mm; P = 0.02).
At a median follow-up of 771 days, freedom from TLR was 81% for the different-DES approach vs. 72% for the same-DES approach (log rank P = 0.067). A similar advantage for the alternate-DES strategy was seen for event-free survival (figure 1).
In addition, after propensity score adjustment, a treatment effect favoring the different-DES strategy was observed for MLD (difference in means 0.41, 95% CI 0.19-0.62; P = 0.001), recurrent restenosis (RR 0.41, 95% CI 0.21-0.80; P = 0.01), MACE (composite of cardiac death, MI, and TLR; HR 0.56, 95% CI 0.33-0.96; P = 0.038), and TLR (HR 0.62, 95% CI 0.39-1.01; P = 0.06).
In a separate analysis, recurrent restenosis was reduced when in-stent restenosis was treated with second-generation DES compared with non-second-generation DES (16% vs. 28%; P = 0.04).
Dr. Alfonso stressed that treatment of in-stent restenosis remains challenging, and because some patients experience very late events, prolonged surveillance is recommended. Larger studies with new-generation DES are required to confirm these results, he added.
Source:
Alfonso F. RIBS-III: A prospective multicenter registry of the use of the same or different stents after coronary drug-eluting stent restenosis. Presented at: Transcatheter Cardiovascular Therapeutics 2011; November 8, 2011; San Francisco, CA.
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Disclosures
- Dr. Alfonso reports no relevant conflicts of interest.
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