CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Paul Vermeersch, MD,
Pierfrancesco Agostoni, MD*,
Stefan Verheye, MD, PhD,
Paul Van den Heuvel, MD,
Carl Convens, MD,
Frank Van den Branden, MD and
Glenn Van Langenhove, MD, PhD
* Antwerp Cardiovascular Institute Middelheim, AZ Middelheim, Lindendreef 1, 2020, Antwerp, Belgium (Email: agostonipf{at}gmail.com).
We really welcome the additional data provided by Dr. Bansal and colleagues over the mid- and long-term outcome of drug-eluting stents (DES) in diseased saphenous vein grafts (SVGs). We also appreciate the words of caution expressed by the authors and focused on a more careful use of DES in this type of lesion. Indeed, their data, as well as our long-term data from the DELAYED RRISC (Death and Events at Long-term follow-up AnalYsis: Extended Duration of the Reduction of Restenosis In Saphenous vein grafts with Cypher stent) trial (1), and the data from Chu et al. (2), all point out that in the long term DES seem not to maintain the possible advantages shown in the midterm. Another additional study (a sub-study of the large prospective STENT [Strategic Transcatheter Evaluation of New Therapies] registry), recently presented as an abstract, also showed no differences between DES and bare-metal stents in SVGs (3). To our knowledge, while there are some data showing benefit of DES over bare-metal stents in the midterm (up to 6 to 9 months), there are no registries showing the same benefit in the long term (>1 year). The only long-term study is the one previously mentioned, and all show a similar trend without clear advantage of DES over bare-metal stents.
However, we have to underline some issues related to all these analyses. On the one hand, our data are focused only on sirolimus-eluting stents and not on other types of DES (1). On the other hand, the data of Dr. Bansal and colleagues, of Chu et al. (2), and of the STENT registry (3) were based on analyses encompassing different types of DES. Whether their results were mainly driven by a suboptimal performance of one type of DES over the others or whether there is a "class-effect" of DES in SVG, this cannot be evinced by the data provided. New prospective studies are undergoing in order to also offer additional data on other types of DES, such as polymeric paclitaxel-eluting stents (4). In addition, as all of these studies analyzed de-novo lesions in SVGs, we have a total lack of data on the way DES perform in restenotic SVG lesions.
While waiting for a conclusive large and well-powered randomized trial of DES versus bare-metal stents in SVGs, in our opinion the use of DES in this lesion subset in daily life clinical practice should be discouraged (unless prospectively evaluated in a study). If there is a willingness to implant a DES in a diseased SVG, this should be firmly discussed with the patient, and a careful assessment of the possible advantages and risks related to the implantation of this device should be cautiously evaluated. Moreover, we welcome interventional cardiologists that implanted DES in SVGs to try to collect long-term data on their patients in order to provide additional data to the scientific community, like Dr. Bansal et al. remarkably did in their letter.
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Footnotes
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Please note: Dr. Agostoni received lecture fees from Cordis Belgium and from Jolife.
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References
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- Vermeersch P, Agostoni P, Verheye S, et al. DELAYED RRISC (Death and Events at Long-term follow-up AnalYsis: Extended Duration of the Reduction of Restenosis In Saphenous vein grafts with Cypher stent) Investigators Increased late mortality after sirolimus-eluting stents versus bare-metal stents in diseased saphenous vein grafts: results from the randomized DELAYED RRISC trial J Am Coll Cardiol 2007;50:261-267.[Abstract/Free Full Text]
- Chu WW, Rha SW, Kuchulakanti PK, et al. Efficacy of sirolimus-eluting stents compared with bare metal stents for saphenous vein graft intervention Am J Cardiol 2006;97:34-37.[ISI][Medline]
- Wilson BH, Humphrey AD, Cedarholm JC, et al. Drug-eluting stents are no better than bare metal in vein grafts: results from the strategic transcatheter evaluation of new therapies (STENT) group(abstr) J Am Coll Cardiol 2007;49(Suppl B):41B.
- The SOS (Stenting Of Saphenous vein grafts) randomized-controlled trial of a paclitaxel-eluting stent vs. a bare metal stent in saphenous vein graft lesionshttp://www.clinicaltrials.gov/ct/show/NCT00247208;jsessionid=6F9441EDA4CF004B3764ADFC6749F935?order=1 2007Accessed November 12, 2007.
Related Article
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Percutaneous Intervention in Saphenous Vein Bypass Graft Disease: Case Against the Use of Drug-Eluting Stents
- Darpan Bansal, Rajesh Sachdeva, and Jawahar L. Mehta
J. Am. Coll. Cardiol. 2008 51: 970-971.
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