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(BQ) Part 2 book “900 questions - An interventional cardiology board review” has contents: Closure devices, interventional coronary physiology, intravascular ultrasound, peripheral interventional procedures, cerebrovascular interventions, congenital heart disease, statistics related to interventional cardiology procedures,… and other contents.
18 Stents Stephen G Ellis Questions With bare-metal stents (BMSs), direct stenting compared with stenting after predilatation results in: (A) Less target lesion revascularization (TLR) at months (B) Shorter procedure times (C) Less target vessel revascularization (TVR) at months (D) A and C (E) All of the above Angiographic correlates of stent thrombosis within 30 days of bare metal stenting include: (A) Dissection remaining after stenting (B) Stent length (C) Final minimal lumen diameter (MLD) (D) A and C (E) All of the above A 53-year-old man undergoes left anterior descending (LAD) artery stent for exertional angina After stent deployment, there is intraluminal linear dissection Is it safe to leave this alone after bare metal stenting? (A) It is safe to leave mild luminal haziness alone but not intraluminal linear dissection (B) Yes, it is safe to leave mild luminal haziness and intraluminal linear dissection alone (C) Yes, it is safe to leave mild luminal haziness and intraluminal linear dissection alone, provided the patient is on glycoprotein IIb/IIIa antagonists (D) No, it is not safe to leave any dissection behind 142 Correlates of stent thrombosis occurring to months after bare metal stenting include: (A) Extensive plaque prolapse (B) Radiation therapy (C) Disruption of adjacent vulnerable plaques (D) Stenting across side branches (E) A, B, and C (F) All of the above Recognized complications of balloon rupture during stent implantation occurring in at least 10% of ruptures include: (A) Coronary spasm (B) Coronary perforation (C) Coronary dissection (D) A and C (E) None of the above Before implantation, coronary stents should not be touched by the operator because: (A) There is greater risk of restenosis (B) Glove talc may induce coronary spasm (C) There is risk of infection (D) Touching stents gently really does not matter (E) A and C A 36-year-old female smoker presents to you for evaluation For the last 12 months, she has experienced morning chest pain, which does not get worse with exercise She had an extensive workup with her primary cardiologist and was found to have variant angina She is continuing to have chest Stents pain on Norvasc, aspirin (ASA), and extended release nitroglycerin She searched on the Internet and found that stenting might help Expected outcomes of bare metal stenting for variant angina include: (A) Improved but not total angina control (B) Little, if any, improvement in symptoms (C) Higher than usual risk of restenosis (D) A and C Which of the following is not a correlate of diffuse in-stent restenosis (ISR) with BMSs? (A) Small reference vessel diameter (RVD) (B) Coil stents (C) Female gender (D) High balloon inflation pressure (E) None of the above (A) (B) (C) (D) 143 3% 5% 7% 10% 14 When limited to BMSs, when feasible, the best approach in treating a type bifurcation lesion is: (A) Stent across the side branch and finish with kissing balloon for side branch compromise (B) Predilatate the side branch, stent across, and finish with kissing balloon (C) Use cutting balloon for the side branch, stent across, and finish with kissing balloon (D) T-stenting (E) Culotte stenting What is the relationship between intimal hyperplasia measured by intravascular ultrasound (IVUS) and stent size or BMSs? (A) Intimal hyperplasia is independent of stent size (B) Intimal hyperplasia is greater for large stents (C) Intimal hyperplasia is greater for small stents 15 The likelihood of important side branch narrowing after high-pressure stent implantation across a side branch in a side branch with a >50% ostial narrowing is: (A) 20% (B) 30% (C) 40% (D) 50% or higher 10 The best IVUS cross-sectional area (CSA) cutoff correlating restenosis in BMSs is: (A) mm2 (B) mm2 (C) mm2 (D) 10 mm2 (E) Once you factor in RVD, final CSA does not matter 16 The likelihood of important side branch narrowing after high-pressure stent implantation across a side branch in a branch without ostial narrowing is: (A) 7% (B) 15% (C) 20% (D) 25% 11 The expected rate of TLR for proliferative pattern of bare metal stent-in-stent restenosis treated with either balloon angioplasty or bare metal stenting is: (A) (B) (C) (D) 25% 35% 50% 70% 17 For BMSs, which characteristic has been convincingly shown to influence restenosis rate? (A) Coil versus tubular design (B) Strut thickness (C) Longitudinal flexibility (D) A and C (E) All of the above 12 The expected rate of TLR for focal pattern of bare metal stent-in-stent restenosis treated with either balloon angioplasty or bare metal stenting is: (A) 10% (B) 15% (C) 20% (D) 25% (E) 30% 18 The expected TLR rate at months for a contemporary BMS placed into a 3.5-mm vessel requiring a 15-mm length stent in a nondiabetic is: (A) 3% (B) 5% (C) 8% (D) 10% (E) 12% 13 The absolute TVR benefit for BMSs compared with balloon angioplasty for lesions in vessels with RVD 30 days The pathologic mechanisms of late stent thrombosis were stenting across ostia of major arterial branches, exposure to radiation therapy, plaque disruption in the nonstented arterial segment within mm of the stent margin, and stenting of markedly necrotic, lipid-rich plaques with extensive plaque prolapse and diffuse ISR (Circulation 2003;108:1701–1706) Answer D Balloon rupture is a rare complication during stent implantation, which can usually be 146 managed with stents (Am J Cardiol 1997;80:1077– 1080) Answer A In vivo analysis of rinsed versus nonrinsed stents demonstrated a reduced neointimal thickness, neointimal area, and vessel percent stenosis in rinsed, compared with nonrinsed, stents A significant reduction in the inflammatory infiltrate around struts was also observed in untouched stents (J Am Coll Cardiol 2001;38:562–568) Answer A Twenty percent of patients with variant angina are resistant to medical therapy For these patients, stenting has improved angina control However, in a small study, 33% of the patients continued to have angina after stent implantation (J Am Coll Cardiol 1999;34:216–222) Answer E Diffuse restenosis was associated with a smaller RVD, longer lesion length, female gender, longer stent length, and the use of coil stents Aggressive forms of ISR occur earlier and with more symptoms, including MI (J Am Coll Cardiol 2001;37: 1019–1025) Answer A Intimal hyperplasia CSA and thickness at follow-up were calculated and compared with stent CSA and circumference There was a weak, but significant correlation between mean and maximum intimal hyperplasia CSA versus stent CSA However, there was no correlation between mean or maximum intimal hyperplasia thickness versus stent CSA or stent circumference Intimal hyperplasia thickness was found to be independent of the stent size (Am J Cardiol 1998;82:1168–1172) 10 Answer C Patients with restenosis have a significantly longer total stent length, smaller reference lumen diameter, smaller final MLD by angiography, and smaller stent lumen CSA by IVUS In lesions without restenosis, patients had 9.4 ± 3.4 mm CSA versus 8.1 ± 2.7 mm (p 10 mm within the stent, pattern III includes ISR >10 mm extending outside the stent, and pattern IV is totally occluded ISR TLR increased with increasing ISR class; it was 19%, 35%, 50%, and 83% in classes I to IV, respectively 12 Answer C See explanation for Question 11 (Circulation 1999;100:1872–1878) 13 Answer B Moreno et al (J Am Coll Cardiol 2004;43:1964–1972) performed a meta-analysis of 11 randomized trials comparing coronary stenting versus balloon angioplasty in small coronary vessels The pooled rates of restenosis were 25.8% and 34.2% in stent versus balloon patients, respectively (p = 0.003) Stented patients had lower rates of major adverse cardiac events (15.0% vs 21.8%, p = 0.002; RR 0.70; 95% CI, 0.57 to 0.87) and new TVRs (12.5% vs 17.0%, p = 0.004; RR 0.75, 95% CI, 0.61 to 0.91) 14 Answer A Balloon angioplasty of coronary bifurcation lesions is associated with a lower success and higher complication rate Suwaidi et al (J Am Coll Cardiol 2000;35:929–936) performed a study where they treated 131 patients with bifurcation lesions Patients were divided into two groups: Group where a stent was deployed in one branch and percutaneous transluminal coronary angioplasty (PTCA) in the side branch, and Group where stent deployment occurred in both branches Group was then divided into two subgroups depending on the technique of stent deployment The Gp2a subgroup underwent Y-stenting, and the Gp2b subgroup underwent T-stenting After 1-year follow-up, no significant differences were seen in the frequency of major adverse events (death, MI, or repeat revascularization) between Gp2a and Gp2b Adverse cardiac events were higher with Y-stenting compared with T-stenting (86.3% vs 30.4%, p = 0.004) Stenting of both branches offers no advantage over stenting one branch and performing balloon angioplasty of the other branch (J Am Coll Cardiol 2000;35:929–936, J Am Coll Cardiol 2000;35:1145–1151) 15 Answer D Aliabadi et al (Am J Cardiol 1997;80: 994–997) evaluated the incidence, angiographic predictors, and clinical outcome of side branch occlusion following stenting in 175 patients By multivariate analysis, the presence of side branches with >50% ostial narrowing that arose from within or just beyond the diseased portion of the parent 147 vessel was an angiographic predictor of side branch occlusion At 9-month follow-up there was no difference in combined clinical events between those patients with and without side branch occlusion 16 Answer A See explanation for Question 15 (Am J Cardiol 1997;80:994–997) 17 Answer A Early coil stents had poor radial strength, allowing considerable tissue prolapse and higher restenosis rate Thicker struts result in more intense formation of neointimal hyperplasia, which may result in higher restenosis rate Longitudinal flexibility is associated with deliverability (Textbook of interventional cardiology, Vol 2003:591–630) 18 Answer B In the recent DES trials such as SIRIUS (Sirolimus-Eluting Stent in de novo Native Coronary Lesions), TAXUS IV, and TAXUS V, TLR rate for BMS in 3.5 to 4.0 mm was only 5% at months 19 Answer C Serruys et al (Lancet 1998;352:673– 681) randomized patients to either clinical and angiographic follow-up or clinical follow-up alone in stent versus balloon angioplasty trial At months, a primary clinical endpoint had occurred in 12.8% of the stent group and in 19.3% of the angioplasty group (p = 0.013) This significant difference in clinical outcome was maintained at 12 months In the subgroup assigned angiographic follow-up, restenosis rates occurred in 16% of the stent group and in 31% of the balloon angioplasty group (p = 0.0008) In the group assigned clinical followup alone, event-free survival rate at 12 months was higher in the stent group than in the balloon angioplasty group (0.89 vs 0.79, p = 0.004) 20 Answer F Herzog et al (Circulation 2002;106: 2207–2211) analyzed dialysis patients in the United States hospitalized from 1995 to 1998 for first coronary revascularization procedures The in-hospital mortality was 8.6% for CABG patients, 6.4% for PTCA patients, and 4.1% for stent patients The 2year all-cause survival was highest for CABG patients and lowest for stent patients 21 Answer D Passing a wire adjacent to the stent and compressing the stent against the sidewall of the vessel is probably the safest and easiest method in this situation To pass a snare device into a calcified mid-RCA would be difficult and sending the patient to surgery without attempting stent compression is not prudent It may be quite difficult to pass a wire through an undeployed stent 148 900 Questions: An Interventional Cardiology Board Review 22 Answer D Cheneau et al (Circulation 2003;108: 43–47) analyzed 7,484 consecutive patients without acute MI who were treated with PCI and stenting and who underwent IVUS imaging during the intervention Of these, 0.4% had angiographically documented subacute closure