Coronary Stenting or Balloon Angioplasty for Chronic Total Coronary Occlusions: The Taiwan Experience (A Single-Center Report)

Abstract

The authors conducted this study to compare the restenosis and reocclusion rates of primary balloon angioplasty alone versus angioplasty followed by stenting in Taiwanese patients with chronic total occlusions. They also evaluated whether stenting reduced the incidence of restenosis and improved left ventricular function in these patients. From October 1998 to April 2000, a total of 294 patients with chronic total occlusion (Thrombolysis in Myocardial Infarction grade 0 flow) underwent recanalization using balloon angioplasty alone or followed by stent implantation. Of these, only 129 patients were included after procedural failure and patients lost to follow-up; 62 patients were placed in the stent group, while 67 patients were assigned to the percutaneous transluminal coronary angioplasty (PTCA) group. Coronary angiography was performed at baseline and at 6 months follow-up or earlier if angina or objective evidence of ischemia involving the target vessel or other vessels was present. Procedural success was 60%. Minimal lumen diameter increased significantly after stenting: 2.97 ±0.41 vs 2.24 ±0.41 (p<0.001); 60% of patients in the stent group were free of restenosis, whereas only 33% in the PTCA group were free of restenosis at follow-up. Only 1 patient in the stent group had reocclusion, as opposed to 17 (25%) patients in the PTCA group (p<0.001). The follow-up minimal lumen diameter (MLD) at 6 months was significantly larger in the stent group: 1.80 ±0.85 mm vs 1.08 ±0.82 mm (p<0.001). Left ventricular function improved in the stent group, but not in the PTCA group (58.44 ±16.58% to 63.60 ±14.59% [p<0.001] vs 54.13 ±15.66% to 54.31 ±15.60% [p=0.885]). More patients had angina in the PTCA group than in the stented group 43 vs 29 (p=0.053). The postprocedural MLD and reference vessel diameter (RVD) were the strong predictors of restenosis and follow-up MLD (p<0.001). Stenting of chronically occluded arteries significantly reduced the incidence of reocclusion and restenosis, at the same time improving left ventricular function in these patients. This should be the procedure of choice after successful angioplasty of chronically occluded vessels.

Get full access to this article

View all access options for this article.

References

Serruys PW , Umans V , Heyndrickx GR , et al : Elective PTCA of totally occluded coronary arteries not associated with myocardial infarction: Short-term and long-term results. Eur Heart J 6:2-12, 1985.

Sanborn TA : Recanalization of arterial occlusions: Pathologic basic and contributing factors. J Am Coll Cardiol 13:1558-1560, 1989.

Ellis SG , Shaw RE , Gershony G , et al : Risk factors, time course and treatment effect for restenosis after successful percutaneous transluminal coronary angioplasty of chronic total occlusion. Am J Cardiol 63:897-901, 1989.

Tan W , Sulke AN , Taub NA , et al : Determinants of success of coronary angioplasty in patients with a chronic total occlusion: A multiple logistic regression model to improve selection of patients. Br Heart J 70:126-131, 1993.

Stewart JT , Denne L , Bowker TJ , et al : Percutaneous transluminal coronary angioplasty in chronic coronary artery occlusion. J Am Coll Cardiol 21:1371-1376, 1993.

Bell MR , Berger PB , Bresnahan JF , et al : Initial and long-term outcome of 354 patients after coronary balloon angioplasty of total coronary occlusions. Circulation 85:1003-1011, 1992.

Maiello L , Colombo A , Giatuossi R , et al : Coronary angioplasty of chronic occlusions: Factors predictive of procedural success. Am Heart J 124:581-584, 1992.

Buller CE , Dzavik V , Carere RG , et al : Primary stenting versus balloon angioplasty in occluded coronary arteries: The total occlusion study of Canada (TOSCA). Circulation 100:236-242, 1999.

Sirnes PA , Golf S , Myreng Y , et al : Sustained benefit of stenting chronic coronary occlusion: Long-term clinical follow-up of the stenting in chronic coronary occlusion (SICCO) study. J Am Coll Cardiol 32:305-310, 1998.

10.

Sirnes PA , Golf S , Myreng Y , et al : Stenting in chronic coronary occlusion (SICCO): A randomized, controlled trial of adding stent implantation after successful angioplasty. J Am Coll Cardiol 28:1444-1451, 1996.

11.

Rubartelli P , Niccoli L , Verna E , et al : Stent implantation versus balloon angioplasty in chronic coronary occlusions: Results from the GISSOC trial. Gruppo Italiano di Studio sullo Stent nelle Occlusioni Coronariche. J Am Coll Cardiol 32:90-96, 1998.

12.

Sievert H , Rohde S , Utech A , et al : Stent or angioplasty after recanalization of chronic coronary occlusions? (The SARECCO Trial). Am J Cardiol 84:386-390, 1999.

13.

Hoher M , Wohrle J , Grebe OC , et al : A randomized trial of elective stenting after balloon recanalization of chronic total occlusions. J Am Coll Cardiol 34:722-729, 1999.

14.

Mori M , Kurogane H , Hayashi T , et al : Comparison of results of intracoronary implantation of the Palmaz-Schatz stent with conventional balloon angioplasty in chronic total coronary arterial occlusion. Am J Cardiol 78:985-989, 1996.

15.

Lotan C , Rozenman Y , Hendler A , et al : Stents in Total Occlusion for restenosis Prevention: The multicenter, randomized STOP study. Eur Heart J 21:1960-1966, 2000.

16.

Puma JA , Sketch MH , Tcheng JE , et al : Percutaneous revascularization of chronic coronary occlusions: An overview. J Am Coll Cardiol 26:1-11, 1995.

17.

Stone GW , Rutherford BD , McConahay DR , et al : Procedural outcome of angioplasty for total coronary artery occlusion: An analysis of 971 lesions in 905 patients. J Am Coll Cardiol 15:849-856, 1990.

18.

Gordon PC , Gibson CM , Cohen DJ , et al : Mechanisms of restenosis and redilation within coronary stents-quantitative angiographic assessment. J Am Coll Cardiol 21:1166-1174, 1993.

19.

Belle EV , Blouard P , McFadden E , et al : Effects of stenting of recent or chronic coronary occlusions on late vessel patency and left ventricular function. Am J Cardiol 80:1150-1154, 1997.

20.

Dzavik V , Carere RG , Mancini GBJ , et al : Predictors of improvement in left ventricular function after percutaneous revascularization of occluded coronary arteries: A report from the Total Occlusion Study of Canada (TOSCA). Am Heart J 142:301-308, 2001.

21.

Escaned J , Cortes J , Alcocer MA , et al : Long-term angiographic results of stenting in chronic total occlusions: Influence of stent design and vessel size. Am Heart J 138:675-680, 1999.

22.

Rau T , Schofer J , Schluter M , et al : Stenting of nonacute total coronary occlusions: Predictors of late angiographic outcome. J Am Coll Cardiol 31:275-280, 1998.

23.

Hall P , Nakamura S , Maiello L , et al : A randomized comparison of combined ticlopidine and aspirin therapy versus aspirin therapy alone after successful intravascular ultrasound-guided stent implantation. Circulation 93:215-222, 1996.

24.

Albiero R , Hall P , Itoh A , et al : Results of a consecutive series of patients receiving only antiplatelet therapy after optimized stent implantation (Comparison of aspirin alone versus combined ticlopidine and aspirin therapy). Circulation 95:1145-1156, 1997.

25.

Bertrand ME , Legrand V , Boland J , et al : Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting: The full anticoagulation versus aspirin and ticlopidine (FANTASTIC) Study. Circulation 98:1597-1603, 1998.

26.

Schuhlen H , Kastrati A , Pache J , et al : Sustained benefit over four years from an initial combined antiplatelet regimen after coronary stent placement in the ISAR trial. Am J Cardiol 87:397-400, 2001.

27.

Leon MB , Baim DS , Gordon P , et al : Clinical and angiographic results from the stent anticoagulation regimen study (STARS) (abstract). Circulation 94(suppl I):I-685, 1996.