β Scribed by Feldman, Ted
No coin nor oath required. For personal study only.
Miyazaki et al. report a striking correlation between postpercutaneous transluminal coronary angioplasty (PTCA) residual stenosis and long-term outcomes in a large population of patients treated with balloon angioplasty between 1985 and 1990. They point out the importance of a bigger result at the end of a revascularization procedure and emphasize the ''bigger is better'' principle (Fig. ) [2] as a clear goal of catheter interventions, irrespective of the type of intervention. Three groups of patients were described: those with less than 15% residual stenosis, a group with an intermediate result of 15-35% residual stenosis, and a group with 35-50% residual stenosis. The total survival and the event-free survival were significantly related to the degree of residual stenosis when considered categorically in these three groups and also in a multivariate analysis. The study was performed prior to the widespread use of atherectomy, stenting, and effective adjuvant drug therapy. We have been preoccupied with the use of stents as a method to achieve a larger lumen. This report emphasizes that there are other ways to achieve a bigger lumen and good long-term outcome, especially in smaller arteries. The results highlight the critical and independent importance of achieving a good acute angiographic result.
It is important to evaluate the study population in any interventional report. The population presented in this paper is a real-world patient group. The mean reference vessel size for these patients was 2.5-2.6 mm in diameter. This is substantially smaller than the reference diameters reported for stent and device intervention patients from whom the ''bigger is better'' concept was derived. It has been reported that 70-90% of patients treated with stents in today's practices are not patients who would have been included in trials such as STRESS and Benestent. The smaller reference vessel size in this study highlights this difference. This population is also unique in having 32-34% diabetics. This is significantly higher than the 15-20% rate reported in most other interventional groups. It is also notable in the paper by Miyazaki et al. [1] that the group of patients with 35-50% residual stenosis had a high rate of vessel calcification. This suggests that the degree of residual stenosis is at least in part a function of vessel characteristics. Multivessel PTCA was performed in about one fourth of these patients, also a group not represented in most of the recent studies from which our concepts regarding the development of restenosis have emerged.
π SIMILAR VOLUMES