Direct Infarct Artery Stenting Without Predilation and No-Reflow
Direct Infarct Artery Stenting Without Predilation and No-Reflow
Background: In patients with acute myocardial infarction (AMI), the rate of microvascular embolization and no-reflow promoted by coronary stenting with the use of conventional techniques (CS) appears to be greater than the one that occurs with balloon angioplasty. The minor invasiveness of direct stenting (DS) of the infarct artery without predilation could be expected to reduce embolization in the coronary microvasculature and no-reflow in patients with AMI.
Methods: In a cohort of 423 consecutive patients with AMI who underwent infarct-artery stenting, we compared CS and DS in terms of angiographic no-reflow rate and 1-month clinical outcome.
Results: At baseline patients who underwent DS (n = 110) had a better risk profile compared with the use of CS (n = 313). The incidence of angiographic no-reflow was 12% in the CS group and 5.5% in the DS group (P = .040). The 1-month mortality rate was 8% in the CS group and 1% in the DS group (P = .008). The mortality rate was 11% in patients with no-reflow and 5.6% in patients with a normal flow. Multivariate analysis showed that age, preprocedure patent infarct artery, and lesion length were related to the risk of no-reflow. In the subset of patients with a target lesion length <15 mm, the variables independently related to the risk of no-reflow were age, DS, and final balloon inflation pressure.
Conclusions: DS in patients with AMI may reduce the incidence of angiographic no-reflow, thereby increasing ultimate effective myocardial reperfusion.
Primary infarct-related artery (IRA) stenting may be superior to conventional primary coronary angioplasty in patients with acute myocardial infarction (AMI). Provisional infarct artery stent implantation improves the primary success rate, whereas elective stent implantation reduces the incidence of early and late infarct artery restenosis or reocclusion and related cardiac events, mainly the need for repeat target vessel revascularization. However, concluded randomized trials comparing primary infarct artery stenting and primary coronary angioplasty have shown no benefit of stenting in terms of reduction of the incidence of angiographic no-reflow phenomenon, which is strongly related to mortality. In the largest trial, infarct artery stenting was associated with a trend toward a lower incidence of Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow at the end of the procedure compared with angioplasty alone. On the other hand, an acute reduction of a normal angiographic flow after balloon angioplasty may be observed after stent deployment and expansion, suggesting that the negative effect on distal flow may be the consequence of increased atherosclerotic and thrombotic material embolization in the microvasculature.
Direct stenting (DS) without predilation is a new stenting technique that may reduce procedural time, radiation exposure time, and costs. In addition to these advantages, DS could be expected to reduce embolization of plaque constituents and the incidence of the no-reflow phenomenon, thereby increasing perfusion and myocardial salvage in patients with AMI.
The aim of this prospective observational study was the assessment of the impact of DS of the infarct artery on the angiographic no-reflow phenomenon in patients with AMI.
Background: In patients with acute myocardial infarction (AMI), the rate of microvascular embolization and no-reflow promoted by coronary stenting with the use of conventional techniques (CS) appears to be greater than the one that occurs with balloon angioplasty. The minor invasiveness of direct stenting (DS) of the infarct artery without predilation could be expected to reduce embolization in the coronary microvasculature and no-reflow in patients with AMI.
Methods: In a cohort of 423 consecutive patients with AMI who underwent infarct-artery stenting, we compared CS and DS in terms of angiographic no-reflow rate and 1-month clinical outcome.
Results: At baseline patients who underwent DS (n = 110) had a better risk profile compared with the use of CS (n = 313). The incidence of angiographic no-reflow was 12% in the CS group and 5.5% in the DS group (P = .040). The 1-month mortality rate was 8% in the CS group and 1% in the DS group (P = .008). The mortality rate was 11% in patients with no-reflow and 5.6% in patients with a normal flow. Multivariate analysis showed that age, preprocedure patent infarct artery, and lesion length were related to the risk of no-reflow. In the subset of patients with a target lesion length <15 mm, the variables independently related to the risk of no-reflow were age, DS, and final balloon inflation pressure.
Conclusions: DS in patients with AMI may reduce the incidence of angiographic no-reflow, thereby increasing ultimate effective myocardial reperfusion.
Primary infarct-related artery (IRA) stenting may be superior to conventional primary coronary angioplasty in patients with acute myocardial infarction (AMI). Provisional infarct artery stent implantation improves the primary success rate, whereas elective stent implantation reduces the incidence of early and late infarct artery restenosis or reocclusion and related cardiac events, mainly the need for repeat target vessel revascularization. However, concluded randomized trials comparing primary infarct artery stenting and primary coronary angioplasty have shown no benefit of stenting in terms of reduction of the incidence of angiographic no-reflow phenomenon, which is strongly related to mortality. In the largest trial, infarct artery stenting was associated with a trend toward a lower incidence of Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow at the end of the procedure compared with angioplasty alone. On the other hand, an acute reduction of a normal angiographic flow after balloon angioplasty may be observed after stent deployment and expansion, suggesting that the negative effect on distal flow may be the consequence of increased atherosclerotic and thrombotic material embolization in the microvasculature.
Direct stenting (DS) without predilation is a new stenting technique that may reduce procedural time, radiation exposure time, and costs. In addition to these advantages, DS could be expected to reduce embolization of plaque constituents and the incidence of the no-reflow phenomenon, thereby increasing perfusion and myocardial salvage in patients with AMI.
The aim of this prospective observational study was the assessment of the impact of DS of the infarct artery on the angiographic no-reflow phenomenon in patients with AMI.