Faculty Bibliography

BACKROUND:In-stent restenosis (ISR) remains a common clinical problem associated with significant morbidity. We sought to evaluate the temporal trends in incidence and procedural management of coronary restenosis as well as evaluate the association between different treatment modalities and clinical outcomes. METHODS:We identified all patients treated for coronary ISR within the Veterans Affairs Healthcare System from October 1, 2006 to September 30, 2014. The temporal trends in incidence as well as intraprocedural management were assessed. Among patients treated for single vessel restenosis, a propensity matched cohort was created for those treated with drug-eluting stents (DES) or other treatment modalities. Target vessel revascularization (TVR) and mortality were compared between the two subpopulations. RESULTS:From 2006 to 2014, 65,443 patients underwent percutaneous coronary intervention and 6,872 patients (10.5%) with 8,921 lesions were treated for ISR. The proportion of patients undergoing revascularization for restenosis increased 0.28% per year (P = 0.055). Among a propensity-matched cohort of 6,231, the rates of TVR (subdistribution HR: 0.623, 95% CI: 0.511-0.760) and mortality (HR: 0.730, 95% CI: 0.641-0.830) were significantly lower among patients treated with a DES compared with other treatments. After adjustment for known risk factors, treatment with DES continued to be associated with a reduction in mortality rate (Adjusted HR: 0.802, 95% CI: 0.704-0.913). CONCLUSIONS:There is a trend toward an increasing proportion of coronary interventions for ISR in a national cohort of Veterans and treatment with a DES is associated with the lowest rate of TVR and overall mortality.

BACKGROUND:Studies comparing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery in patients with multivessel coronary artery disease (CAD) have shown lower repeat revascularization rates in patients who undergo CABG. The reason remains unclear. METHODS:We identified patients with multivessel CAD who received CABG or PCI enrolled in the Duke Databank for Cardiovascular Disease (2003 to 2012). We compared the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) between the two groups. Clinically performed follow-up angiograms for CABG patients were reviewed to determine adequacy of intervenable targets. RESULTS:A total of 1555 patients were included: 861 underwent PCI and 694 underwent CABG. Patients with index PCI were more often female, African-American, presented with ST-elevation myocardial infarction (MI), and had previous MI; they were less often diabetic and had less heart failure or proximal left anterior descending disease. The adjusted hazard ratio of MACCE for CABG vs PCI was 0.68 (95% confidence interval, 0.58-0.80; P<.001). The adjusted odds ratio for repeat revascularization for CABG vs PCI was 0.45 (95% confidence interval, 0.28-0.72; P<.001). Fifty-seven patients with index CABG were found to have ≥1 occluded graft on subsequent angiography without repeat revascularization; 48 patients (6.9%) had inadequate targets for intervention. CONCLUSION:Among patients with multivessel CAD, repeat revascularization rates are lower among CABG patients compared with PCI patients. However, a high proportion of CABG patients with occluded grafts on repeat angiography lack targets for repeat revascularization. This may partially explain the disparity in repeat revascularization rates and suggests that future comparison studies should additionally assess angiographic outcomes.

BACKGROUND:Patients with end-stage renal disease undergoing percutaneous coronary intervention (PCI) have largely been excluded from trials of antithrombotic therapies leaving little data to guide agent choice in this population. METHODS AND RESULTS:The National Cardiovascular Data Registry CathPCI Registry was used to identify patients with end-stage renal disease undergoing PCI who received monotherapy with either bivalirudin or unfractionated heparin (UFH) (n=71 675). In hospital bleeding and mortality were compared and adjusted using the CathPCI Registry logistic regression models with generalized estimating equations with UFH as the reference. Bivalirudin was used in 51.3% of patients versus 48.7% for UFH. The use of bivalirudin decreased over time, and in 2014, UFH became the most frequently used. Patients receiving UFH were more likely to have an acute coronary syndrome presentation (37.8% versus 27.4%) or have cardiogenic shock (3.74% versus 1.98%). The observed rates for in hospital bleeding (7.0% versus 9.5%; adjusted odds ratio,0.82; 95% confidence interval, 0.76-0.87) and mortality (2.6% versus 4.2%; adjusted odds ratio, 0.87; 95% confidence interval, 0.78-0.97) were lower for patients receiving bivalirudin compared with those receiving UFH. CONCLUSIONS:In patients with end-stage renal disease undergoing PCI, bivalirudin and UFH were used with similar frequency although the patterns of use changed over the enrollment period. Patients with end-stage renal disease undergoing PCI had a lower adjusted risk of in hospital outcomes with bivalirudin; however, given the observational nature of this analysis, a randomized trial is warranted.

OBJECTIVES:This study was conducted to determine the association between radial access, guided femoral access, and non-guided femoral access on postprocedural bleeding and vascular complications after percutaneous coronary intervention (PCI). BACKGROUND:Bleeding events and major vascular complications after PCI are associated with increased morbidity, mortality, and cost. While the radial approach has been shown to be superior to the femoral approach in reducing bleeding and vascular complications, whether the use of micropuncture, fluoroscopy, or ultrasound mitigates these differences is unknown. METHODS:We conducted a post hoc analysis of women in the SAFE-PCI for Women trial who underwent PCI and had the access method identified (n = 643). The primary endpoint of postprocedure bleeding or vascular complications occurring within 72 hours or at discharge was adjudicated by an independent clinical events committee and was compared based on three categories of access technique: radial, guided femoral (fluoroscopy, micropuncture, ultrasound), or non-guided femoral (none of the aforementioned). Differences between the groups were determined using multivariate logistic regression using radial access as the reference. RESULTS:Of the PCI population, 330 underwent radial access, 228 underwent guided femoral access, and 85 underwent non-guided femoral access. There was a statistically significant lower incidence of the primary endpoint with radial access vs non-guided femoral access; however, there was no significant difference between radial approach and femoral access guided by fluoroscopy, micropuncture, or ultrasound. CONCLUSIONS:This post hoc analysis demonstrates that while radial access is safer than non-guided femoral access, guided femoral access appears to be associated with similar bleeding events or vascular complications as radial access.

OBJECTIVES/OBJECTIVE:We sought to characterize how the perceived risk of early dual antiplatelet therapy (DAPT) discontinuation is incorporated into operator decision-making regarding stent choice, using a simple pre-procedure survey screening for clinical variables that may lead to early DAPT discontinuation. BACKGROUND:Understanding which factors influence operator decision-making regarding stent choice during percutaneous coronary intervention (PCI) could help identify areas for quality improvement. METHODS:We retrospectively identified 1202 patients who underwent PCI from July 2008 to January 2013 at the Durham Veterans Affairs Medical Center. We excluded patients without a complete pre-procedure survey within 14days of PCI, repeat procedures on the same patient and those who received both drug-eluting stents (DES) and bare-metal stents (BMS) or no stent during PCI, leaving 864 patients. The primary outcome was the independent association of "yes" responses to survey items with the odds of DES use during PCI. RESULTS:Of 864 patients, 661 received DES and 203 received BMS. A "yes" response to "planned major surgery or dental work in the next year" (OR 0.20, 95% CI 0.11-0.36, p<0.001), "recent bleeding event or bleeding diathesis" (OR 0.31, 95% CI 0.14-0.68, p=0.003) or "currently taking Coumadin" (OR 0.39, 95% CI 0.19-0.78, p=0.007) was independently associated with lower odds of DES use. CONCLUSIONS:Responses to 3 items on a simple pre-procedure survey screening for clinical variables that may lead to early DAPT discontinuation were independently associated with stent type used during PCI, suggesting the importance of these factors in an operator's stent choice.

BACKGROUND:Current guidelines give a class I recommendation to use of embolic protection devices (EPD) for saphenous vein graft (SVG) intervention; however, studies have shown conflicting results. The objective of this meta-analysis is to compare all-cause mortality, major adverse cardiovascular events, myocardial infarction (MI), or target vessel revascularization in SVG intervention with and without EPD. METHODS AND RESULTS/RESULTS:=0.30) between the 2 groups. Sensitivity analysis excluding CathPCI Registry study showed no difference in periprocedural MI, late MI, and target vessel revascularization; however, it favored EPD use in all-cause mortality and major adverse cardiovascular events. Further sensitivity analysis including only observational studies revealed no difference in all-cause mortality, major adverse cardiovascular events, target vessel revascularization, and late MI. Additional analysis after excluding CathPCI Registry study revealed no difference in outcomes. CONCLUSIONS:This study including 52 893 patients suggests no apparent benefit in routine use of EPD during SVG intervention in the contemporary real-world practice. Further randomized clinical trials are needed in current era to evaluate long-term outcomes in routine use of EPD, and meanwhile, current guideline recommendations on EPD use should be revisited.

OBJECTIVES:The study sought to define patient, operator, and institutional factors associated with transradial access (TRA) in ST-segment elevation myocardial infarction (STEMI) percutaneous coronary intervention (PCI), the variation in use across operators and institutions, and the relationship with mortality and bleeding. BACKGROUND:TRA for PCI in STEMI is underutilized. Factors associated with TRA are not well described, nor is there variation across operators and institutions or their relationship with outcomes. METHODS:The authors used hierarchical logistic regression to identify patient, operator, and institutional characteristics associated with TRA use as well as determine the variation in TRA for STEMI PCI from 2009 to 2015. They also described the relationship between operator- and institution-level use and risk-adjusted bleeding and mortality. RESULTS:Among 692,433 patients undergoing STEMI PCI, 12% (n = 82,618) utilized TRA. TRA increased from 2% to 23% from 2009 to 2015, but with significant geographic variation. Age, sex, cardiogenic shock, cardiac arrest, operators entering practice before 2012, and nonacademically affiliated institutions were associated with lower rates of TRA. There was significant operator and institutional variation, wherein identical patients would have >8-fold difference in odds of TRA for STEMI PCI by changing operators (median odds ratio: 8.7), and >5-fold difference by changing institutions (median odds ratio: 5.1). Greater TRA use across operators was associated with reduced bleeding (rho = -0.053), whereas TRA use across institutions was associated with reduced mortality (rho = -0.077). CONCLUSIONS:Transradial access for STEMI PCI is increasing, but remains underutilized with significant geographic, operator, and institutional variation. These findings suggest an ongoing opportunity to standardize STEMI care.