Target vessel revascularization

Elevated homocysteine concentrations have been associated with an increased risk for cardiovascular disease in both epidemiologic and clinical studies.43 Several studies have evaluated the benefit of lowering homocysteine levels with folic acid supplementation. One study reported a reduction in major cardiac events with the combination of folic acid, vitamin B12, and vitamin B6 following PCI.44 However, a more recent study found an increased risk of instent restenosis and the need for target-vessel revascularization with folate supplementation following coronary stent placement.45 The role of folate in the management of IHD is currently unclear. 

The pivotal US trial for the Paclitaxel stent was the TAXUS IV trial, which enrolled 1,314 patients with single de novo coronary lesions (Length 10-28 mm and diameter 2.5-3.75 mm) [67] (Fig. 5.7). Target vessel revascularization based on ischemic symptoms was reduced from 12 to 4.7% p < 0.001). The rate of restenosis by angiography was considerable lower (7.9% versus 26.6% p < 0.001), with no difference in the rate of cardiac death, myocardial infarction, or stent thrombosis. 

Abbreviations MI, myocardial infarction PCI, percutaneous coronary intervention PEP, primary endpoint TVR, target vessel revascularization UR, urgent reintervention. 

In the NICE-3 study (14), 661 ACS patients were treated with enoxaparin SC I mg/kg plus abciximab, eptifibatide, or tirofiban at standard doses. Two strategies were combined for the transition from the ward to the catheter laboratory no interruption and no addition of enoxaparin for PCI within eight hours of the last SC injection and an additive IV bolus of 0.3 mg/kg when PCI was performed between 8 and 12 hours of the last SC injection. The major bleeding rate was 4.5% and the in-hospital death/MI/urgent target vessel revascularization rate was 5.7%. 

The major findings of this study showed that patients treated with oral prednisone had a significant lower major adverse cardiac and cerebrovascular event (MACCE) (P = 0.0063), any target vessel revascularization (P = 0.001), and binary restenosis (P = 0.001) than those allocated in the placebo group. Twelve-month event-free survival rates were 93% and 65% in patients treated with prednisone and placebo, respectively (relative risk 0.18, 95% confidence intervals 0.05-0.61),... 

Major findings of IMPRESS II were a significant reduction of target vessel revascularization, MACCE, and restenosis, Event-free survival at 12 months was 93% in prednisone-treated patients versus 69.8% in control (P = 0.006). 

Abbreviations-. MACCE, major adverse cardiac and cerebrovascular events TVR, target vessel revascularization. ... 

During the one year of follow-up including in-hospital events, MACCE occurred in 15 of 76 of patients (20%) 13 target-vessel revascularization, one repeat PCI and stenting in a nontarget vessel, and one myocardial infarction (this patient also had an emergency PCI after the initial procedure). 

The rate of clinically driven target lesion or target vessel revascularization was significantly lower in oral sirolimus compared with control (Table 7). Target vessel revascularization was 5/60 (8.3%) versus 21/55 (38%), respectively (P < 0.001), and the target lesion revascularization was 5/66 (7.6%) versus 22/59 (37.2%), respectively (P < 0.001). Target vessel failure and major adverse cardiovascular events were also improved with oral sirolimus therapy (P = 0.01 and P = 0.03 I, respectively, Table 7). 

Figure 3 shows the survival curves of freedom from target vessel revascularization (Fig. 3A) and freedom from major adverse cardiovascular events (Fig. 3A) showing significantly better outcome in those patients treated with oral sirolimus, that is, the numbers represent an 80% reduction of target vessel revascularization and 55% reduction of major adverse cardiovascular events compared to the control group. 

Event-free survival from target vessel revascularization (A) and major adverse cardiovascular events (B). 

Also, studies investigating the use of ICB with patients with SVG ISR had a significantly reduced need for repeat target-lesion revascularization, but not target-vessel revascularization (TVR) or combined TVR-MACE endpoints (28,29). 

Ajani AE, Waksman R, Cha D, et al. The impact of lesion length and reference vessel diameter on angiographic restenosis and target vessel revascularization in treating in-stent restenosis with radiation. J Am Coll Cardiol 2002 39 1290-1296. 

Structure of BRILLIANT EU. Abbreviations IVUS, intravascular ultrasound MACE, major adverse cardiac events MLA, minimal luminal area MLD, minimal luminal diameter QCA, qualitative coronary angiography SAT, subacute stent thrombosis TLR, target lesion revascularization TVF, target vessel failure TVR, target vessel revascularization. 

The enhanced suppression of platelet receptor llb/llla using integrilin therapy (ESPIRIT) trial of nonurgent PCI demonstrated a significant reduction in the incidence of post-PCI Ml at 30 days but not death or urgent target vessel revascularization using eptifibatide in terms of MACE (34). However, this trial randomized patients to receive placebo in the control arm. 

Trial (Ref.) Year Target vessel revascularization Death, MI, and TVR ... 

TVR = Ischemia-driven target vessel revascularization. GRAMI = In-hospital outcomes. 

Figure 4.3 Inddence of major adverse cardiac events (death, myocardial infarction, disabling stroke, or ischania-driven target vessel revascularization) at 6 months in the CADILLAC trial (34).

Corpus RA, George PB, House JA, Dixon SR, Ajluni SC, Devhn WH, Timmis GC, Balasubramaniam M, O Neill WW. Optimal glycemic control is associated with a lower rate of target vessel revascularization in treated type II diabetic patients undergoing elective percutaneous coronary intervention. J Am Coll Cardiol 2004 43 8-14. 

In the analysis of events occurring after one year (events within the first year after stent implantation having been censored from review), biodegradable polymer DES were associated with a reduction in the risk of target vessel revascularization compared with BMS (33% reduction), but not compared with any other kind of durable polymer DES. Biodegradable DES also did not reduce the risk of MI compared to BMS or... 

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