Ravi K. Ramana

Long-term clinical outcomes of real-world experience using sirolimus-eluting stents in saphenous vein graft disease

Objective: To evaluate the long‐term clinical outcomes of patients undergoing percutaneous coronary intervention for saphenous vein graft (SVG) disease. Specifically, we compared clinical endpoints of patients who received sirolimus‐eluting stents (SES) versus bare‐metal stents (BMS) for SVG disease. Background: A recent small randomized‐controlled trial (RCT) reported increased mortality with the use of SES in SVG disease. Methods: We retrospectively identified patients who underwent SES placement for a SVG lesion(s) at our institutions over a 4‐year period. The procedural and medical records were reviewed to identify predetermined clinical outcomes. Results: 318 patients who underwent SES placement for a SVG lesion were identified. 7 patients were lost to follow‐up. 141/311 patients (45%) received SES, while 170/311 (55%) received BMS. At a mean follow‐up of 34 months, there was a reduction in target lesion revascularization (TLR) (7% vs. 14%, P = 0.07) without an increased risk of mortality (6% vs. 12%, P = 0.06) in patients who received SES compared to patients who received BMS. When compared to the recent RCTs SES patients at long‐term follow‐up, our SES patients had significantly less mortality; rates of myocardial infarction, TLR, target vessel revascularization, and major adverse cardiac events; and were more likely to be taking dual antiplatelet and statin medications. Conclusion: Our results support that SES used in SVG lesions result in a reduction in TLR without an increased risk of mortality, and therefore may be an equally safe and feasible technique for revascularization with excellent long‐term clinical outcomes. These patients may benefit from prolonged dual antiplatelet and statin medication regimens.

Percutaneous coronary intervention in patients with acute coronary syndrome: focus on bivalirudin

Previously, indirect thrombin inhibitors such as unfractionated heparin or low-molecular-weight heparin were used as a standard anticoagulation during percutaneous coronary intervention to prevent procedural thrombotic complications but at a risk of hemorrhagic complications. More recently, bivalirudin, a member of the direct thrombin inhibitor class, has been shown to have 1) predictable pharmacokinetics, 2) ability to inhibit free- and clot-bound thrombin, 3) no properties of platelet activation, 4) avoidance of heparin-induced thrombocytopenia, and 5) a significant reduction of bleeding without a reduction in thrombotic or ischemic endpoints compared to heparin and glycoprotein IIbIIIa inhibitors when used in patients presenting with acute coronary syndrome who are planned for an invasive treatment strategy.