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‘Full-metal jacket’ stenting for CTO yields acceptable long-term outcomes
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The “full-metal jacket” procedure using drug-eluting stents for PCI in patients with chronic total occlusions is associated with acceptable safety and durability over 5 years, according to published data.
The researchers evaluated 1,126 procedures performed in 1,107 patients who were prospectively enrolled in the CTO registry from 2003 to 2015 at Asan Medical Center in South Korea.
Use of the full-metal jacket procedure, which was performed in more than one-third of patients overall (36.7%), became more common over time, with the frequency increasing from 28.5% during 2003 to 2006 to 41.7% after 2011, according to the data.
Among the 406 patients who underwent full-metal jacket stenting, the mean stent length was 76.8 mm, the mean number of stent overlaps was 2.5 and the majority were performed in the right coronary artery. Persistent luminal narrowing at the distal reference segment after stenting was observed in 127 patients, Pil Hyung Lee, MD, from the department of cardiology at Asan Medical Center, and colleagues reported.
During a median follow-up of 5.1 years, the rate of target lesion failure — a composite of cardiac death, target vessel-related MI or target lesion revascularization or reocclusion — was 16%. There were 23 cases of cardiac death, 10 cases of periprocedural MI, nine cases of spontaneous MI, 17 cases of total reocclusion, five cases of definite stent thrombosis and one case of probable stent thrombosis. Target vessel revascularization was also attempted in 25 patients, including eight with in-stent reocclusion.
The researchers found persistent luminal narrowing at the distal segment of stents at the index procedure in 11 of the 17 patients with in-stent reocclusion.
In multivariable analysis, predictors of an increased risk for TLF included the number of implanted stents (HR = 1.72; 95% CI, 1.16-2.54) and persistent distal luminal narrowing (HR = 2.73; 95% CI, 1.66-4.47).
In an accompanying editorial, Subhash Banerjee, MD, from University of Texas Southwestern Medical Center, and Emmanouil S. Brilakis, MD, PhD, from Minneapolis Heart Institute, Abbott Northwestern Hospital, wrote that the 5-year rates of TLF and TLR observed in the study “are well within the accepted range for complex PCI with contemporary DES.”
They highlighted the high rate of persistent distal luminal narrowing, but wrote that the finding should be viewed in a larger context and that lack of a comparison group that did not undergo full-metal jacket stenting prevents a comparative assessment.
“The results of the present study provide reassurance regarding the safety and long-term durability of [full-metal jacket] stenting of CTO and possibly non-CTO diffusely diseased vessels,” wrote Banerjee and Brilakis, both members of the Cardiology Today’s Intervention Editorial Board. “This information can be used for informed decision-making by both patients and operators performing CTO PCI. These decisions hinge on the balance between anticipated benefits and risks (both immediate and long-term) prior to undertaking the now ‘en vogue’ [full-metal jacket] stenting of coronary CTOs.” – by Melissa Foster
Disclosures: The researchers report no relevant financial disclosures. Banerjee reports receiving honoraria from Medtronic, Gore and AstraZeneca, and research grants from Boston Scientific and Merck. Brilakis reports receiving consultant/speaker honoraria from Abbott Vascular, Asahi, Cardinal Health, Elsevier, GE Healthcare and St. Jude Medical; research support from InfraRedx and Boston Scientific; and his spouse is an employee of Medtronic.
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