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CLINICAL STUDY: INTERVENTIONAL CARDIOLOGY

A randomized comparison of the value of additional stenting after optimal balloon angioplasty for long coronary lesions

Final results of the additional value of nir stents for treatment of long coronary lesions (ADVANCE) study

Patrick W. Serruys, MD, PhD, FACC, FESC^*,*, David P. Foley, MRCPI, PhD, FACC, FESC^*, Martin-Jan Suttorp, MD, PhD, Benno J. W. M. Rensing, MD, PhD, Harry Suryapranata, MD, PhD, FESC, Phillipe Materne, MD, Arijan van den Bos, MD^||, Edouard Benit, MD, FESC, FACC^¶, Angelo Anzuini, MD^#, Wolfgang Rutsch, MD, FESC^**, Victor Legrand, MD, PhD, FESC, Keith Dawkins, MD, FRCP, Michael Cobaugh, Marco Bressers, MSc^||||, Bianca Backx, PhD^||||, William Wijns, MD, PhD^¶¶ and Antonio Colombo, MD, FACC, FESC^#

^* Erasmus University, Rotterdam, The Netherlands
Sint Antonius Ziekenhuis, Nieuwegein, The Netherlands
Ziekenhuis De Weezenlanden, Zwolle, The Netherlands
Hôpital de la Citadelle, Liège, Belgium
^|| Medisch Centrum "De Klokkenberg", Breda, The Netherlands
^¶ UZ Virga Jesse, Hasselt, Belgium
^# Centro Cuore Columbus, Milan, Italy
^** Universitätsklinikum Charité, Berlin, Germany
CHU Sart Tilman, Liège, Belgium
Wessex Cardiology Centre, Southampton, United Kingdom
Boston Scientific GmbH, Ratingen, Germany
^|||| Cardialysis, Rotterdam, The Netherlands
^¶¶ Onze Lieve Vrouw Ziekenhuis, Aalst, Belgium.

Manuscript received July 10, 2001; revised manuscript received October 17, 2001, accepted November 1, 2001.

^* Reprint requests and correspondence: Prof. P. W. Serruys, Department of Interventional Cardiology, Heart Center, Erasmus University Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
serruys{at}card.azr.nl

	Abstract

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OBJECTIVES: We sought to investigate the clinical benefit of additional stent implantation after achieving an optimal result of balloon angioplasty (BA) in long coronary lesions (>20 mm).

BACKGROUND: Long coronary lesions are associated with increased early complications and late restenosis after BA. Stenting improves the early outcome, but stent restenosis is also related to both lesion length and stent length.

METHODS: A total of 437 patients with a single native lesion 20 to 50 mm in length were included and underwent BA, using long balloons matched to lesion length and vessel diameter (balloon/artery ratio 1.1) to achieve a diameter stenosis (DS) <30% by on-line quantitative coronary angiography (QCA). "Bail-out stenting" was performed for flow-limiting dissections or >50% DS. Patients in whom an optimal BA result was achieved were randomized to additional stenting (using NIR stents) or no stenting. The primary end point was freedom from major adverse cardiac events (MACE) at nine months, and core laboratory QCA was performed on serial angiograms.

RESULTS: Bailout stenting was necessary in 149 patients (34%) and was associated with a significantly increased risk of peri-procedural infarction (p < 0.02). Among the 288 randomized patients, the mean lesion length was 27 ± 9 mm, and the vessel diameter was 2.78 ± 0.52 mm. The procedural success rate was 90% for the 143 patients assigned to BA alone (control group), as compared with 93% in the 145 patients assigned to additional stenting (stent group), which resulted in a superior early minimal lumen diameter (0.54 mm, p < 0.001) and led to reduced angiographic restenosis (27% vs. 42%, p = 0.022). Freedom from MACE at nine months was 77% in both groups.

CONCLUSIONS: A strategy of provisional stenting for long coronary lesions led to bailout stenting in one-third of patients, with a threefold increase in peri-procedural infarction. Additional stenting yielded a lower angiographic restenosis rate, but no reduction in MACE at nine months.

Abbreviations and Acronyms   MACE   BA   balloon angioplasty   CK   creatine kinase   DS   diameter stenosis   IVUS   intravascular ultrasound   MACE   major adverse cardiac events   MI   myocardial infarction   MLD   minimal lumen diameter   TIMI   Thrombolysis In Myocardial Infarction   TVR   target vessel revascularization   QCA   quantitative coronary angiography

In focal lesions, the concept of "provisional stenting" (11) has demonstrated that a "stent-like" or "optimal" result using BA achieves clinical and angiographic results equivalent to those of stent implantation, so that stenting could be reserved for lesions in which an optimal result cannot be achieved (12–14). The value of additional stenting after achievement of an optimal BA result in long coronary lesions has not been investigated; therefore, this study was initiated.

	Methods

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Study group.   Patients with stable or unstable angina or reversible ischemia related to a single, native, primary coronary lesion 20 to 50 mm in length, in a vessel 2.5 to 4.0 mm in diameter, were eligible for inclusion. Exclusion criteria included myocardial infarction (MI) within the five days before enrolment, Q-wave MI with akinesia in the target vessel territory, ejection fraction <30%, history of stroke, gastrointestinal bleeding within six months, severe hepatic disease, serum creatinine >130 µmol/liter, contraindication to or intolerance of aspirin or ticlopidine, unprotected left main coronary artery lesion, total occlusion (Thrombolysis in Myocardial Infarction [TIMI] trial flow grade 0), bifurcation lesion (side branch >2.0 mm), aorto-ostial lesion and large intra-luminal thrombus.

Trial design.   This prospective, randomized, multicenter trial assumed a 40% incidence of the primary end point (i.e., cumulative major adverse cardiac events [MACE] at nine months) in the control group (optimal BA result, randomized to no additional stenting) and 26% in the stent group (optimal BA result, randomized to additional stenting). A total of 500 patients (2 x 250) were required to obtain a power of 90% with = 0.05 for a two-tailed test. With an anticipated 20% to 25% rate of bail-out stenting, 650 patients were needed to retain 500 evaluable patients.

Trial procedure and randomization.   Suitable patients gave written, informed consent before undergoing angiography before the intervention. Ticlopidine, 250 mg twice daily, or clopidogrel, 75 mg/day, was administered to all patients within 12 h before the intervention and for one month subsequently to those undergoing stent implantation. Heparin (10,000 U) and aspirin (250 mg intravenously) were given according to standard protocol; aspirin, 100 mg/day, was continued indefinitely. Use of the platelet glycoprotein IIb/IIIa receptor antagonist was at the discretion of the investigators.

After baseline angiography had established the patients’ suitability for inclusion, the allocation service was telephoned to report inclusion and provide patient identity, lesion length, vessel diameter and diameter stenosis (DS) by on-line quantitative coronary angiography (QCA). Target lesion BA was then performed to achieve DS <30% without significant dissection, using balloons of sufficient length to cover the entire lesion with a single inflation and a final balloon/artery ratio of 1.1. When an optimal result had been achieved, whereby in daily practice the procedure would be considered successfully completed, the trial randomization service was again telephoned to report BA procedural success, lesion length, vessel diameter and post-angioplasty diameter stenosis. Then randomization took place, either to no further therapy or to additional stenting. When bail-out stenting had been performed, the allocation service was also called to report this.

In patients randomized to no further therapy, the final post-BA angiographic views were recorded for off-line analysis at the core laboratory. In those randomized to additional stenting, premounted NIR stents (Boston Scientific Corp., Maple Grove, Minnesota) of the appropriate length and diameter were implanted to achieve an optimal result, using the least number of stents possible, while fully covering the lesion (ideally a single stent) (Table 1). So-called "spot stenting" was excluded. The NIR stents were available in diameters from 2.5 to 4.0 mm and lengths of 9, 16, 25 and 32 mm.

End points and definitions.   The primary end point was the occurrence of MACE during nine months of follow-up, defined previously (15) as the occurrence of cardiac death, MI, coronary artery bypass graft surgery or repeat percutaneous transluminal coronary angioplasty (i.e., target vessel revascularization [TVR]).

Cardiac death.   All deaths were considered as cardiac-related, unless unequivocally documented as noncardiac (based, whenever possible, on an autopsy). Myocardial infarction was defined as 1) development of new abnormal Q waves (Minnesota Code) not present at study inclusion (baseline); and 2) an increase of creatine kinase (CK) of more than twice the upper limit of normal and an abnormal level of CK-MB isoenzyme, measured routinely at screening and 6 and 12 h after the intervention and where clinically indicated.

Target vessel revascularization.   The procedure of TVR, defined as the repeat treatment of a lesion in a previously treated vessel, was justified by recurrent symptoms and/or reversible ischemia in advance of repeat catheterization, or diminished coronary flow reserve or fractional flow reserve, combined with DS >50% during repeat catheterization. Telephone notification to the allocation center was required before repeat revascularization, for documentation and justification.

Treatment success.   Core laboratory criteria for angiographic success were DS <50% and TIMI flow grade 3 in the control group and DS <30% and TIMI flow grade 3 in the stent group. Procedural success was measured angiographically and by the absence of MACE during the hospital period. In the group randomized to additional stenting, strategic success was defined by attainment of the "first-choice" stent strategy (Table 1).

Ethical conduct.   This study was conducted in accordance with the Declaration of Helsinki. Patients received detailed, written information on the trial and gave written consent according to national requirements. No center started until written approval of the protocol and consent procedure was obtained from the appropriate Ethical Review Committee and Institutional Review Board. The study complied with Good Clinical Practice and European Standard EN 540, governing the conduct of clinical investigations of medical devices. Source data verification was performed.

Angiographic procedures.   Coronary angiography was performed in at least two views after intracoronary injection of 0.1 to 0.3 mg of nitroglycerin or 1 to 3 mg of isosorbide dinitrate at baseline and repeated after BA and after stenting and at follow-up angiography for the randomized patients. Standardized procedures were followed to facilitate quantitative analysis at the core laboratory (Cardialysis, Rotterdam, The Netherlands, using the CAAS II system [PIE Medical, Maastricht, The Netherlands]), as extensively described previously (4,6,9,12,15).

Follow-up.   All patients visited the out-patient clinic at one, six and nine months after the intervention; an exercise tolerance test was also performed at six months, and in randomized patients, follow-up angiography was carried out on the same day or at least within the next two weeks, according to well-described standardized procedures.

Statistical analysis.   Primary end points were analyzed according to the intention-to-treat principle. Safety analysis was performed for all patients included. Ordinal variables were analyzed by the Fisher exact test; continuous variables by analysis of variance; MACE-free survival in the primary efficacy group at nine months by the log-rank test; and event-free survival distributions by the Kaplan-Meier method.

	Results

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Interim analysis.   A planned interim analysis after 280 patients completed nine months of follow-up was performed in September 1999. Survival free of MACE was lower in the additional stenting group than in the control group (81% vs. 86%, p = NS). Because the hypothesized advantage of additional stenting over BA (a 14% reduction in MACE) could not be substantiated with the existing trial design, the Safety and Data Monitoring Board recommended that patient recruitment be curtailed and the 437 patients included (Tables 2 and 3) be followed and analyzed, according to the protocol.

View larger version (19K): [in this window] [in a new window]   figure 1 Cumulative distribution of minimal lumen diameter (mld) before the procedure (pre), after the procedure (post) and at six-month follow-up (fup) for the balloon angioplasty only group (n = 120; solid line) and the additional stenting group (n = 124; dashed line).

Follow-up (Tables 4, 5 and 6, Fig. 1). .   The incidence of MACE at nine months was similar between the two groups, at 23%. There was also no difference in MLD at follow-up (0.08 mm, p = NS), although angiographic restenosis was higher in the control group than in the additional stenting group (42% vs. 27%, p = 0.022). The incidence of TVR tended to be higher in the additional stenting group than in the control group (34 vs. 28), and 20% of TVR in the stent group was in lesions with DS <50%, as compared with only 9% in the control group.

	Discussion

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The Additional Value of NIR Stents for Treatment of Long Coronary Lesions (ADVANCE) trial was the first to evaluate provisional stenting in longer lesions. Because of the intricacies of combining physiologic and on-line QCA measurements in a multicenter trial, with the complexity of long lesions, optimization of BA would be determined by on-line QCA alone.

The surprising revelation of the interim analysis, that the MACE rate was actually higher in the additional stenting group, led to advice by the independent Safety and Data Monitoring Board to the Steering Committee to terminate inclusion, because the initial trial hypothesis could no longer be demonstrated, which would have rendered continuing inclusion of patients both futile and unethical. What was surprising was the lower than expected rate of MACE of 20% in the BA-only group at that time (23% finally), as compared with an expected rate of 40%. This may partly reflect differences in patient selection for randomized trials, compared with day-to-day practice, and be partly explained by the higher than anticipated bail-out stenting rate of 34%, which may have "removed" many patients at higher risk of late MACE from the BA group.

Clinical implications.   When embarking on this trial, three theoretical outcomes were considered. First, the additional value of stenting could have been demonstrated, whereby this policy would have been recommended. Second, stenting could have been found to be detrimental, in which case, its restriction to bailout would have been concluded. The third possibility, and the ultimate finding, was that additional stenting was neither advantageous nor detrimental to the clinical outcome, which brings about a clinical dilemma. This study has not answered the question: should we stent long lesions? It has, however, demonstrated that an initial strategy of attempting optimal BA leads to bail-out stenting in one-third of patients, with a threefold increased risk of peri-procedural infarction, which is detrimental to the long-term clinical outcome (18,19). Accordingly, intentional stenting might be a safer and more effective initial strategy, by avoiding the bail-out situation. In retrospect, inclusion of an additional randomization to intentional stenting at the time of the first allocation might have provided data that would elucidate this possibility. However, the required sample size needed to demonstrate superiority of this strategy would have been cost-prohibitive, so the current design was chosen.

The majority of late events was TVR at follow-up angiography (Fig. 2), which was artificially higher in the stent group, as previously reported in BENESTENT-2 (20), despite our policy of prospective justification for proposed re-interventions. Clinical follow-up, without routine angiography, would likely have led to a lower TVR rate in the stent group and hence a better clinical outcome (immediately before follow-up angiography, 90% of the stent group was MACE-free vs. 85% of the BA group) (Fig. 2). It might have been useful to include such a sub-randomization, but in this scenario, the sample size required would have been excessive, and it was expected that clinical justification of TVR would be followed.

View larger version (15K): [in this window] [in a new window]   Figure 2 Event-free survival during 300 days after the intervention (by the Kaplan-Meier method). Thickest line = additional stenting group (n = 145); medium-thick line = balloon angioplasty only group (n = 143); thin line = bail-out stenting group (n = 149).

Lesion length as a predictor of restenosis: differences between BA and stenting.   Logistic regression analysis of lesion length versus restenosis rate and MACE (Fig. 3) suggested that for lesions 20 to 30 mm, additional stenting was superior to BA, but worse for lesions >40 mm. In the additional stenting group, a lower MACE rate (16.0% vs. 20.3%, p = NS) and a larger MLD at follow-up (1.64 vs. 1.50 mm) were observed for lesions <26 mm, as compared with lesions >26 mm. Furthermore, the TVR rate was significantly lower in those with stents <32 mm (13.1% vs. 23.8%; p = 0.13), and use of multiple stents was associated with an almost doubling of the need for TVR (29.6% vs. 16.7%; p = 0.17), as previously reported (23,24).

View larger version (20K): [in this window] [in a new window]   Figure 3 Logistic regression analysis of lesion length versus major adverse cardiac events (MACE) (top) and restenosis rate (bottom). Both relationships show an advantage of stenting over balloon angioplasty (BA) for shorter lesions; however, in the additional stenting group, there is a significant incremental increase in restenosis and MACE with increased lesion length, a phenomenon that is not seen with BA.

Study limitations.   Randomization to systematic stenting without an optimal BA result might have added important data to the trial and needs to be addressed in future studies. Lack of adjunctive IVUS guidance has been discussed, but because this is not routine in most clinics, the trial is representative of clinical practice.

Conclusions.   A strategy of provisional stenting in long lesions led to bail-out stenting in one-third of the patients, at the cost of a greater than threefold increase in peri-procedural MI. Additional stenting improved early MLD and lowered angiographic restenosis, but without improving nine-month MACE-free survival. These results must be weighed against the potential benefit of systematic stenting, which would reduce the risk of bail-out, taking into account the impending availability of drug-eluting stents, which may reduce or eliminate restenosis.

	Footnotes

 
All of the investigators of the Additional Value of NIR Stents for Treatment of Long Coronary Lesions (ADVANCE) study are listed in the Appendix.

This study was supported by Boston Scientific GmbH, Ratingen, Germany.

	References

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1. Meier B, Gruentzig AR, Hollman J, Ischinger T, Bradford JM. Does length or eccentricity of coronary stenoses influence the outcome of transluminal dilatation? Circulation. 1983;67:497–499[Abstract/Free Full Text]
2. Ellis SG, Roubin GSKing SB III, et al. Angiographic and clinical predictors of acute closure after native vessel coronary angioplasty. Circulation. 1988;77:372–379[Abstract/Free Full Text]
3. Leimgruber PP, Roubin GS, Hollman J. Restenosis after successful coronary angioplasty in patients with single-vessel disease. Circulation. 1986;73:710–717[Abstract/Free Full Text]
4. the Coronary Artery Restenosis Prevention on Repeated Thromboxane Antagonism (CARPORT) Study GroupRensing BJ, Hermans WR, Vos J. Luminal narrowing after percutaneous transluminal coronary angioplasty: a study of clinical, procedural, and lesional factors related to long-term angiographic outcome. Circulation. 1993;88:975–985[Abstract/Free Full Text]
5. Cannon AD, Roubin GS, Hearn JA, Iyer SS, Baxley WA, Dean LS. Acute angiographic and clinical results of long balloon percutaneous transluminal coronary angioplasty and adjuvant stenting for long narrowings. Am J Cardiol. 1994;73:635–641[CrossRef][Medline]
6. BENESTENT Study GroupSerruys PW, de Jaegere P, Kiemeneij F, et al. N Engl JMed . 1994;331:489–495[Abstract/Free Full Text]
7. Fishman DL, Leon MB, Baim D, et al. A randomised comparison of coronary stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med. 1994;331:496–501[Abstract/Free Full Text]
8. Kobayashi Y, De Gregorio J, Kobayashi N. Stented segment length as an independent predictor of restenosis. J Am Coll Cardiol. 1999;34:651–659[Abstract/Free Full Text]
9. Foley DP, Pieper M, Wijns W, et al. The influence of stent length on clinical and angiographic outcomes in patients’ elective stenting for native coronary lesions: final results of the MAGIC 5L study. Eur Heart J. 2001;22:1585–1593[Abstract/Free Full Text]
10. Kastrati A, Elezi S, Dirschinger J, Hadamitzky M, Neumann FJ, Schomig A. Influence of lesion length on restenosis after coronary stent placement. Am J Cardiol. 1999;83:1617–1622[CrossRef][Medline]
11. Foley DP, Serruys PW. Provisional stenting—stent-like balloon angioplasty: evidence to define the continuing role of balloon angioplasty for percutaneous coronary revascularization. Semin Interv Cardiol. 1996;1:269–273[Medline]
12. Serruys PW, de Bruyne B, Carlier S, et al. Randomized comparison of primary stenting and provisional balloon angioplasty guided by flow velocity measurement. (DEBATE 2)Circulation. 2000;102:2930–2937[Abstract/Free Full Text]
13. Stone GW, Hodgson JM, St. Goar FG, et al. Improved procedural results of coronary angioplasty with intravascular ultrasound-guided balloon sizing: the CLOUT pilot trial. Circulation. 1997;95:2044–2052[Abstract/Free Full Text]
14. the Doppler Endpoint STenting INternational Investigation (DESTINI) Study GroupDi Mario C, Moses JW, Anderson TJ, et al. Randomized comparison of elective stent implantation and coronary balloon angioplasty guided by online quantitative angiography and intracoronary Doppler. Circulation. 2000;102:2938–2944[Abstract/Free Full Text]
15. the CARPORT and MERCATOR Study GroupsHermans WR, Foley DP, Rensing BJ, et al. Usefulness of quantitative and qualitative angiographic lesion morphology, and clinical characteristics in predicting major adverse cardiac events during and after native coronary balloon angioplasty. Am J Cardiol. 1993;72:14–20[CrossRef][Medline]
16. Weaver WD, Reisman MA, Griffin JJ, et al. Optimum percutaneous transluminal coronary angioplasty compared with routine stent strategy trial (OPUS-1): a randomised trial. Lancet. 2000;355:2199–2203[CrossRef][Medline]
17. the FROST Study GroupLafont A, Dubois-Rande JL, Steg PG, et al. The French Randomized Optimal Stenting Trial: a prospective evaluation of provisional stenting guided by coronary velocity reserve and quantitative coronary angiography. J Am Coll Cardiol. 2000;36:404–409[Abstract/Free Full Text]
18. Abdelmeguid AE, Topol EJ. The myth of the myocardial ‘infarctlet’ during percutaneous coronary revascularization procedures. Circulation. 1996;94:3369–3375[Free Full Text]
19. Simoons ML, van den Brand M, Lincoff M, et al. Minimal myocardial damage during coronary intervention is associated with impaired outcome. Eur Heart J. 1999;20:1112–1119[Abstract/Free Full Text]
20. Serruys PW, Emanuelsson H, van der Giessen W. Heparin-coated Palmaz-Schatz stents in human coronary arteries: early outcome of the BENESTENT-II pilot study. Circulation. 1996;93:412–422[Abstract/Free Full Text]
21. de Jaegere P, Mudra H, Figulla H, et al. Intravascular ultrasound–guided optimized stent deployment: immediate and 6 months clinical and angiographic results from the Multicentre Ultrasound Stenting in Coronaries (MUSIC) study. Eur Heart J. 1998;19:1214–1223[Abstract/Free Full Text]
22. Hong MK, Park SW, Mintz GS, Lee NH, Lee CW, Kim JJ, Park SJ. Intravascular ultrasonic predictors of angiographic restenosis after long coronary stenting. Am J Cardiol. 2000;85:441–445[CrossRef][Medline]
23. Bauters C, Hubert E, Prat A, et al. Predictors of restenosis after coronary stent implantation. J Am Coll Cardiol. 1998;31:1291–1298[Abstract/Free Full Text]
24. Kastrati A, Schomig A, Elezi S, et al. Predictive factors of restenosis after coronary stent placement. J Am Coll Cardiol. 1997;30:1428–1436[Abstract]
25. Cura FA, Bhatt DL, Lincoff AM, et al. Pronounced benefit of coronary stenting and adjunctive platelet glycoprotein IIb/IIIa inhibition in complex atherosclerotic lesions. Circulation. 2000;102:28–34[Abstract/Free Full Text]
26. Sousa JE, Costa MA, Abizaid A, et al. Lack of neointimal proliferation after implantation of sirolimus-coated stents in human coronary arteries: a quantitative coronary angiography and three-dimensional intravascular ultrasound study. Circulation. 2001;103:192–195[Abstract/Free Full Text]
27. Morice MC, Serruys PW, Sousa JE, et al. The RAVEL study: a randomized study with the sirolimus-coated Bx velocity balloon-expandable stent in the treatment of patients with de novo native coronary artery lesions. (abstr)Eur Heart J. 2001;22:2624

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