Catheterization and Cardiovascular Interventions 84:366–367 (2014)
Editorial Comment One Stent, Two Stent, Three Stent, More Samuel Butman,* MD Verde Valley Medical Center, Cottonwood, Arizona
In medicine, cover-ups such as with skin grafting or patching places where spaces should not be are good, and even better when they last for prolonged periods. It is, after all, all about lasting. In our microcosm of cardiovascular disease, covering the inside of vessels is anything but new and is done with stents, grafts, and stent-grafts in the peripheral arterial system or with a variety of stents in the coronary circulation. We truly want our efforts to last and this 8-year follow-up report of 320 patients who received “full metal jackets” (FMJs) for diffuse disease is reassuring. In the preceding report, 347 patients received FMJs in just over 2 years at one medical center (follow-up was available for 320 of them). Although not knowing the denominator of total interventions, it still comes to about 1 FMJ every 2 days, assuming a 7-day workweek (an even more often if weekends were slower in interventional activity). For this center, placing FMJs was a common event in the study period 10 years ago, between 2003 and 2005. Right out of the gate, it is noteworthy that 3=4 of the patients had intravascular ultrasound guidance during the procedure; so optimal stent deployment was presumably attained or at the least, sought. Many of us have a different population of patients we see (age, clinical presentations, etc.) or different approach to coronary interventions (lower threshold for surgical referral or medical therapy augmentation, etc.), which might make this rate of FMJ higher or lower locally. I just checked my personal database for the last 2 years and found that I only exceeded placing four stents in multivessel interventions. The timeframe for these original procedures likely predates retrograde approaches to chronic total occlusions, and one hopes that most if not all the procedures were not a result of coronary dissections or other untoward events that may have turned procedures from simple to long multiple stent procedures. Technically, one could argue about the low end of their definition of FMJ, that is, 60 mm, but the high C 2014 Wiley Periodicals, Inc. V
end, 150 mm length reported, balances that question. These were all cases of de novo disease, that is, no FMJ into a vein graft (been there, done that). After 8 years, these multivessel disease patients (84% of the group) actually fared relatively well with a survival rate of 91% at follow-up, despite inevitable percutaneous or surgical interventions in many. Although, and it is an important “ALTHOUGH,” if the left ventricular ejection fraction was 80 mm, 5 year survival was in the 70% range. A lower ejection fraction has long represented a known poorer prognosis, while the longer lengths of disease likely point to the many diabetics treated (1 in 3 of the patients in this series) [1]. The latter continues to show a preferred treatment with surgery over percutaneous intervention, except for discrete subsets (e.g., low SYNTAX score) [2,3]. In the past, a control room discussion might have sounded like: Surgeon: “Why did you do that when I could have easily placed some grafts?” Possible Response: “The patient really did not want to have surgery and one thing (stent) led to another (and another). Sorry.” Surgeon: “You should leave a spot to place a graft.” Possible Response: “We cannot, since the spot we leave may be the site of acute stent thrombosis. Sorry.” In fact a surgeon did write just that, albeit more elegantly, in response to a similar report of long-term follow-up of FMJs [4,5]. Where we go in the coming years with absorbable scaffolds, occasionally placed as FMJs, may even be more promising. That would truly be a win–win both for our patients and for our surgical colleagues who may have greater options (i.e., larger target nonstented arteries) if needed. Surely case reports will soon appear and then long-term follow-up will follow suit. This will make any control room chats more constructive and prevent any of those other Conflict of interest: Nothing to report. *Correspondence to: Samuel Butman, MD, 294 West Highway 89A, Cottonwood, AZ 86326. E-mail: [email protected] Received 13 July 2014; Revision accepted 14 July 2014 DOI: 10.1002/ccd.25609 Published online 19 August 2014 in Wiley Online Library (wileyonlinelibrary.com)
One Stent, Two Stent, Three Stent, More
kinds of nonmedical “cover-ups” we read about in the news. REFERENCES 1. DeBusk RF, Blomqvist CG, Kochoukos NT, et al. Identification and treatment of low risk patients after acute myocardial infarction. N Engl J Med 1986;314:161–166. 2. Serruys PW, Morice M-C, Kappetein AP, Colombo A, Holmes DR, Mack MJ, Sta˚hle E, Feldman TE, Brand M, Bass EJ, Dyck NV, Leadley K, Dawkins KD, Mohr FW for the SYNTAX Investigators. Percutaneous coronary intervention versus coronaryartery bypass grafting for severe coronary artery disease. N Engl J Med 2009;360:961–972.
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3. Farkouh ME, Domanski, M, Sleeper LA, Siami FS, Dangas G, Mack M, Yang M, Cohen DJ, Rosenberg Y, Solomon SD, Desai AS, Gersh BJ, Magnuson EA, Lansky A, Boineau R, Weinberge J, Ramanathan K, Sousa JE, Rankin J, Bhargava B, Buse J, Hueb W, Smith CR, Muratov V, Bansilal S, King S, Bertrand M, Fuster V for the FREEDOM Trial Investigators. Strategies for multivessel revascularization in patients with diabetes N Engl J Med 2012;367:2375–2384. 4. Sharp ASP, Latib A, Lelasi A, Larosa C, Godino C, Saolini M, Magni V, Gerber RT, Montorfano M, Carlino M, Michev I, Chieffo A, Colombo A. Long-term follow-up on a large cohort of “full-metal jacket” percutaneous coronary intervention procedures. Circ Cardiovasc Intervent 2009;2:416–422. 5. Lentini S. “Full metal jacket” stenting for coronary artery disease. BMJ 2009;339:b4141.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Editorial Comment One Stent, Two Stent, Three Stent, More Samuel Butman,* MD Verde Valley Medical Center, Cottonwood, Arizona
In medicine, cover-ups such as with skin grafting or patching places where spaces should not be are good, and even better when they last for prolonged periods. It is, after all, all about lasting. In our microcosm of cardiovascular disease, covering the inside of vessels is anything but new and is done with stents, grafts, and stent-grafts in the peripheral arterial system or with a variety of stents in the coronary circulation. We truly want our efforts to last and this 8-year follow-up report of 320 patients who received “full metal jackets” (FMJs) for diffuse disease is reassuring. In the preceding report, 347 patients received FMJs in just over 2 years at one medical center (follow-up was available for 320 of them). Although not knowing the denominator of total interventions, it still comes to about 1 FMJ every 2 days, assuming a 7-day workweek (an even more often if weekends were slower in interventional activity). For this center, placing FMJs was a common event in the study period 10 years ago, between 2003 and 2005. Right out of the gate, it is noteworthy that 3=4 of the patients had intravascular ultrasound guidance during the procedure; so optimal stent deployment was presumably attained or at the least, sought. Many of us have a different population of patients we see (age, clinical presentations, etc.) or different approach to coronary interventions (lower threshold for surgical referral or medical therapy augmentation, etc.), which might make this rate of FMJ higher or lower locally. I just checked my personal database for the last 2 years and found that I only exceeded placing four stents in multivessel interventions. The timeframe for these original procedures likely predates retrograde approaches to chronic total occlusions, and one hopes that most if not all the procedures were not a result of coronary dissections or other untoward events that may have turned procedures from simple to long multiple stent procedures. Technically, one could argue about the low end of their definition of FMJ, that is, 60 mm, but the high C 2014 Wiley Periodicals, Inc. V
end, 150 mm length reported, balances that question. These were all cases of de novo disease, that is, no FMJ into a vein graft (been there, done that). After 8 years, these multivessel disease patients (84% of the group) actually fared relatively well with a survival rate of 91% at follow-up, despite inevitable percutaneous or surgical interventions in many. Although, and it is an important “ALTHOUGH,” if the left ventricular ejection fraction was 80 mm, 5 year survival was in the 70% range. A lower ejection fraction has long represented a known poorer prognosis, while the longer lengths of disease likely point to the many diabetics treated (1 in 3 of the patients in this series) [1]. The latter continues to show a preferred treatment with surgery over percutaneous intervention, except for discrete subsets (e.g., low SYNTAX score) [2,3]. In the past, a control room discussion might have sounded like: Surgeon: “Why did you do that when I could have easily placed some grafts?” Possible Response: “The patient really did not want to have surgery and one thing (stent) led to another (and another). Sorry.” Surgeon: “You should leave a spot to place a graft.” Possible Response: “We cannot, since the spot we leave may be the site of acute stent thrombosis. Sorry.” In fact a surgeon did write just that, albeit more elegantly, in response to a similar report of long-term follow-up of FMJs [4,5]. Where we go in the coming years with absorbable scaffolds, occasionally placed as FMJs, may even be more promising. That would truly be a win–win both for our patients and for our surgical colleagues who may have greater options (i.e., larger target nonstented arteries) if needed. Surely case reports will soon appear and then long-term follow-up will follow suit. This will make any control room chats more constructive and prevent any of those other Conflict of interest: Nothing to report. *Correspondence to: Samuel Butman, MD, 294 West Highway 89A, Cottonwood, AZ 86326. E-mail: [email protected] Received 13 July 2014; Revision accepted 14 July 2014 DOI: 10.1002/ccd.25609 Published online 19 August 2014 in Wiley Online Library (wileyonlinelibrary.com)
One Stent, Two Stent, Three Stent, More
kinds of nonmedical “cover-ups” we read about in the news. REFERENCES 1. DeBusk RF, Blomqvist CG, Kochoukos NT, et al. Identification and treatment of low risk patients after acute myocardial infarction. N Engl J Med 1986;314:161–166. 2. Serruys PW, Morice M-C, Kappetein AP, Colombo A, Holmes DR, Mack MJ, Sta˚hle E, Feldman TE, Brand M, Bass EJ, Dyck NV, Leadley K, Dawkins KD, Mohr FW for the SYNTAX Investigators. Percutaneous coronary intervention versus coronaryartery bypass grafting for severe coronary artery disease. N Engl J Med 2009;360:961–972.
367
3. Farkouh ME, Domanski, M, Sleeper LA, Siami FS, Dangas G, Mack M, Yang M, Cohen DJ, Rosenberg Y, Solomon SD, Desai AS, Gersh BJ, Magnuson EA, Lansky A, Boineau R, Weinberge J, Ramanathan K, Sousa JE, Rankin J, Bhargava B, Buse J, Hueb W, Smith CR, Muratov V, Bansilal S, King S, Bertrand M, Fuster V for the FREEDOM Trial Investigators. Strategies for multivessel revascularization in patients with diabetes N Engl J Med 2012;367:2375–2384. 4. Sharp ASP, Latib A, Lelasi A, Larosa C, Godino C, Saolini M, Magni V, Gerber RT, Montorfano M, Carlino M, Michev I, Chieffo A, Colombo A. Long-term follow-up on a large cohort of “full-metal jacket” percutaneous coronary intervention procedures. Circ Cardiovasc Intervent 2009;2:416–422. 5. Lentini S. “Full metal jacket” stenting for coronary artery disease. BMJ 2009;339:b4141.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
