| | Effectiveness and safety of drug-eluting stents in vein grafts: A meta-analysisReceived 13 July 2009; accepted 12 November 2009. BackgroundThe use of drug-eluting stents (DES) in degenerative vein grafts is currently an off-label indication. Recent studies have had conflicting results regarding the effectiveness and safety of this practice. The objective of this meta-analysis was to compare DES to bare-metal stents for the treatment of vein graft stenosis. MethodsPubMed and the Cochrane clinical trials database were systematically searched to identify all randomized controlled trials (RCTs) and observational studies examining DES for vein graft stenosis published in English between 2003 and 2009. Inclusion criteria included follow-up duration ≥6 months. Data were stratified by study design and pooled using random effects models. ResultsTwenty studies were found to meet our inclusion criteria. Eighteen studies were observational and 2 were RCTs. In observational studies, DES were associated with a reduction in major adverse cardiac events (MACE) (odds ratio [OR] 0.50, 95% CI 0.35-0.72), death (OR 0.69, 95% CI 0.53-0.91), target vessel revascularization (TVR) (OR 0.54, 95% CI 0.37-0.79), and target lesion revascularization (TLR) (OR 0.54, 95% CI 0.37-0.78). The incidence of myocardial infarction was similar between groups. In the RCTs, pooled results were inconclusive because of small sample sizes. ConclusionsAlthough data from observational studies suggest that the use of DES for vein graft stenosis has favorable effects on MACE, death, TVR, and TLR, these data should be interpreted with caution due to their observational nature. Corresponding RCT data are inconclusive. There remains a need for large multicenter RCTs to address the effectiveness and safety of DES for vein graft stenosis. The use of percutaneous coronary intervention (PCI) to treat degenerative vein graft disease is frequent in the drug-eluting stent (DES) era despite vein graft PCI being excluded in the original DES trials. The atherogenic burden in vein grafts is higher, and long-term patency after PCI is lower than PCI in native coronaries. Since their introduction, DES have been used in vein grafts as an off-label indication. Compared to on-label use, off-label use is thought to be associated with increased risks of both early and late stent thrombosis, as well as death and myocardial infarction (MI), as concluded by the Food and Drug Administration.1 In contemporary US practice, off-label use of DES is associated with worse short-term outcomes compared to standard use.2 However, recent data show that within the off-label indications, DES have similar or better rate of death or MI compared to bare-metal stent (BMS) supporting the use of DES in off-label indications.3, 4, 5 Off-label indications, however, represent a variety of anatomical conditions, and vein graft intervention is only one of them. In most recent studies on off-label indications, vein graft represented a fair proportion of cases, but outcomes pertaining to that particular subgroup are not available.2, 3, 4, 5 Recommendations for the use of DES in vein grafts should be based on studies evaluating that specific use. There have been several studies evaluating either the paclitaxel or sirolimus-eluting stent (SES) in vein graft disease. However, these studies have provided conflicting results. We therefore conducted a meta-analysis of randomized controlled trials (RCTs) and observational studies that compared the use of DES to that of BMS for vein graft stenosis. Methods  Our meta-analysis was performed in accordance with the standards set forth by the QUOROM statement (Quality of Reporting of Meta-analyses group).6 We searched the PubMed database up to February 2009, with the keywords “drug-eluting stents,” “sirolimus-eluting stents,” and “paclitaxel-eluting stents” with “vein graft.” We also searched for articles that included off-label indications for DES, in search of vein graft subgroups, and included them if enough subgroup data and outcomes were reported for analysis. Because of the limited number of studies examining this issue, we included both RCTs and observational studies comparing the effectiveness and safety of DES for vein graft stenosis with that of BMS. We excluded case reports, case series, letters, and editorials. We restricted our search to the English literature. In addition, we only included studies with a minimum follow-up of 6 months. If reports involved the same study population, we only included data from the publication with the longest follow-up. Data were extracted independently by 2 reviewers, with disagreements resolved by a third reviewer. Extracted data included study design, baseline demographic and clinical characteristics, duration of follow-up, and outcome data. Clinical outcomes investigated were major advance cardiac events (MACE), all-cause mortality (which included cardiac and noncardiac death), MI, target-lesion revascularization (TLR), and target-vessel revascularization (TVR). Most studies defined MI as a new increase in serum creatine kinase of at least twice the upper limit of the normal reference range with a concomitant rise in the MB fraction or typical rise and fall of troponin with either ischemic symptoms or electrocardiographic evidence of recent infarction. Target-lesion revascularization was most often defined as percutaneous or surgical revascularization of the stented lesion and 5-mm segments immediately proximal and distal to the stent. Major advance cardiac event was most often defined as a composite of death, MI, and TLR, but we included all specific-study definitions of MACE. Statistical methods Data were stratified by study design (ie, observational vs RCT) and were pooled using random effects meta-analysis models. These models compared the effects of DES use to that of BMS use for MACE, all-cause mortality, MI, TLR, and TVR. Treatment effects are presented as odds ratios (ORs) with corresponding 95% CI. Analyses were conducted using MIX version 1.7.7, 8 The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the article, and its final contents. The authors report no conflicts of interest pertaining to this meta-analysis. No extramural funding was used to support this work. Results Our literature search identified 92 potentially relevant abstracts (Figure 1). From these abstracts, we identified 23 potentially relevant studies that were retrieved and reviewed, 17 of which met our inclusion criteria. Finally, after 3 additional studies were identified through a hand search of references, a total of 20 studies were included in our meta-analysis (Figure 1). Eighteen studies were observational studies,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 and 2 were RCTs.27, 28 Fifteen studies were published between 2007 and 2009, reflecting at least 4 years of experience with DES. Six studies involved SES only, 3 involved PES only, 8 involved SES and PES, 1 involved both plus zotarolimus-eluting stents, 1 involved both plus tacrolimus-eluting stents, and 1 study did not specify the type of DES. There were no studies examining the everolimus-eluting stents. A total of 1,989 patients with BMS (1,913 in observational studies and 76 in RCTs) and 1,571 patients with DES (1,482 in observational studies and 79 in RCTs) were included in this meta-analysis. The number of patients evaluated in the observational studies with DES and BMS ranged from 13 to 175 and 13 to 344, respectively. Both RCTs were small and included <50 patients in both stent groups. Study and patient characteristics are summarized in Table I. Most studies assessed the medium-term outcomes (6-12 months after index PCI) of DES. Eleven studies had longer than 12 months outcome assessment, ranging from 18 to 60 months. All studies enrolled patients with de novo lesions in a vein graft. Procedural and lesion characteristics and provided in Table II. Vessel characteristics varied between the studies, with lesion lengths ranging from 8.7 ± 4.8 mm to 19.3 ± 12.5 mm and reference-vessel diameters ranging from 2.9 ± 0.2 mm to 4.0 ± 0.3 mm. Dual antiplatelet therapy, consisting of acetylsalicylic acid and clopidogrel, was recommended for at least 3 to 6 months after PCI in all studies. The use of embolic protection devices was reported in 15 studies and ranged from <5% to 100%. Fourteen studies mentioned the anticoagulation regimen. Of those, 8 used heparin only and 6 used either heparin or bivalirudin. Most studies reported that the use of glycoprotein IIb-IIIa inhibitors was left at the discretion of the operator. The use of glycoprotein IIb-IIIa inhibitors ranged from <10% to >80%. None of the studies provided outcome data in subgroups pertaining to the use of embolic protection device, choice of anticoagulant, or use of glycoprotein IIb-IIIa inhibitors. In the 15 observational studies that examined MACE as an outcome, the use of DES was associated with a substantial decreased risk compared with BMS (OR 0.50, 95% CI 0.35-0.72) (Figure 2). Similarly, the use of DES was associated with decreased mortality (16 studies: OR 0.69, 95% CI 0.53-0.91), TVR (16 studies: OR 0.54, 95% CI 0.37-0.79), and TLR (12 studies: OR 0.54, 95% CI 0.37-0.78) in observational studies examining these outcomes (Figures 3-4, Appendix 1). The effect of DES on MI was inconclusive due to the small number of events that occurred in these observational studies (13 studies, 52 MIs in patients treated with DES vs 83 in patients treated with BMS, OR 0.85, 95%CI 0.48-1.5) (Appendix 2). The 2 RCTs conducted to date have provided conflicting results regarding MACE: one had a trend in favor of BMS and the other had a trend in favor DES. Similarly, DES was associated with a substantial increase in mortality compared to BMS in one RCT, whereas the other reported inconclusive results. Regarding TVR, data from both RCTS favored DES, but both the individual trial data were inconclusive due to wide CIs. In one RCT, DES was associated with a substantial decrease in TLR; data from the other RCT were consistent with these results but were not significant. The 2 RCTs provided conflicting data regarding the effect of DES on MI. Meta-analyses of RCT data examining the effect of DES for vein graft stenosis on MACE, mortality, TVR, TLR, and MI were inconclusive due to the small number of RCTs examining this issue (Table III and Appendix 3, Appendix 4, Appendix 5, Appendix 6, Appendix 7). | | |  | Outcome | Results from meta-analysis of RCTs | Results from meta-analysis of observational studies | |
|---|
| DES (n/N) | BMS (n/N) | OR (95% CI) | DES (n/N) | BMS (n/N) | OR (95% CI) | |
|---|
| MACE | 37/79 | 34/76 | 1.10 (0.34-3.57) | 240/1,135 | 472/1,576 | 0.50 (0.35-0.72) | | | Death | 16/79 | 2/76 | 6.79 (0.62-74.1) | 92/1,342 | 182/1,799 | 0.69 (0.53-0.91) | | | TVR | 13/79 | 14/76 | 0.61 (0.28-1.31) | 177/1,334 | 338/1,791 | 0.54 (0.37-0.79) | | | TLR | 11/79 | 22/76 | 0.35 (0.06-1.84) | 88/989 | 200/1,487 | 0.54 (0.37-0.78) | | | MI | 13/79 | 14/76 | 1.14 (0.12-11.0) | 52/1,038 | 83/1,444 | 0.85 (0.48-1.50) | | | | |
Discussion Our study was designed to examine the effectiveness and safety of DES implantation in vein grafts. As the original large DES trials did not include patients with vein grafts stenosis, the effectiveness and safety of their use in vein grafts remained unstudied until recently. Our meta-analysis of observational studies found that DES was associated with decreased MACE, mortality, TVR, and TLR. However, these data should be interpreted with caution due to biases inherent to observational studies, including confounding by indication. Meta-analyses of available RCT data were inconclusive due to the small number of RCTs available and their relatively small sample sizes. Hence, the effectiveness of DES in vein grafts is not as clear as in native coronary arteries. Vein graft atherosclerosis has a different pathogenesis than native arterial atherosclerosis. Histologically, vein graft lesions are more concentric, diffuse, and involving most of the graft circumference.29 Most graft lesions involve large amounts of inflammatory infiltrates in the intima with no fibrous cap to prevent contact with the blood stream.29 This is in contrast to native arterial lesions that tend to be more eccentric with fewer inflammatory cells and the presence of a fibrous cap.30 Harvested vein grafts tend to experience a loss of endothelium-dependent relaxation,31 and growth factor production is increased inducing a proliferative response.32 Clearly, development of vein graft atherosclerosis differs from native arterial atherosclerosis and vein graft lesions may need to be treated as a different entity. Despite their differences with native arterial lesions, vein graft lesions have been treated widely with DES. Our analysis, which includes 18 retrospective studies, attests to this point. The worldwide enthusiasm regarding the results of the initial DES results led to off-label use for several indications, including vein graft stenosis. Since then, benefits have been retrospectively observed in other off-label indications such has chronic total occlusions33 or restenotic lesions.34 Most DES, as recognized by the Food and Drug Administration, are currently implanted for off-label indications in the United States.1 An analysis of the National Heart, Lung, and Blood Institute Dynamic Registry clearly supports the use of DES in patients with off-label indication, with the authors stating that DES is not associated with higher risk of death or MI and are associated with a reduced need for repeat revascularization at 1 year.3 However, there exist many potential off-label indications, and the effectiveness and safety of the use of DES likely vary among them. For example, in the same off-label analysis, BMS insertion appeared to result in decreased death and MI compared with DES insertion among patients with ostial lesions or left main interventions.3 Whether this is due to different baseline characteristics, confounding by indication where lower risk patients may have received DES or simply stent thrombosis needs to be elucidated. As we report, a significant number of observational studies have been published on this topic but little randomized data are available. Furthermore, there have not been any recent systematic reviews or meta-analyses examining this issue. Despite their small sample sizes, the RCTs do deserve special attention. The first one by Vermeersch et al35 initially reported favorable outcomes at 6 months in restenosis rate, TLR, and TVR. Death and MI were not significantly different initially in this small trial of 75 patients. In a subsequent publication, which is the one included in this analysis, the authors reported the 3-year follow-up. At 3 years, the rates of MI were not different, but the initial reduction in repeat revascularization procedure with DES was lost at long-term follow-up. More striking is that BMS were associated with lower mortality (11 deaths in DES vs 0 in BMS).27 This was statistically significant despite the small size of the trial (75 patients). The higher mortality with DES in this RCT is not clearly seen in the pooled analysis of the observational studies. However, none of studies satisfactorily demonstrate survival benefit with DES either. Even if it did, the question would remain if one should put more weight in a small RCT or large number of pooled data from retrospective unrandomized studies. The second RCT by Brilakis et al28 was also a small trial (80 patients). At a mean follow-up of 18 months, TLR was significantly reduced with a trend toward less TVR and MI. Because of lack of power, similar mortality was reported although it occurred more than twice as often in the DES group. Taken all together, absolute safety has not again been clearly demonstrated. So far, the studies from Vermeersch et al35 and Brilakis et al28 are the only 2 RCTs currently available. According to a search on clinicaltrials.org, another study (BASKETSAVAGE) is ongoing with estimated completion in 2014. Stent thrombosis is the biggest unknown. The long-term effect of drug-coated devices and polymers in a milieu that is more lipid rich, softer, and prone to rupture needs to be clarified. Furthermore, nonintervened segments tend to progress in a degenerative vein graft, which may negate some of the benefits from the antirestenotic properties of DES. Our study has several potential limitations. First, we restricted our literature search to studies published in English. Consequently, our study may be affected by publication and/or language bias. Second, our meta-analysis of observational studies is likely affected by confounding by indication due to the nonrandomized nature of these data. In these studies, the decision to implant DES rather than the less expensive BMS may be due to patient characteristics such as comorbidities and expected survival. This systematic implantation of DES in patients likely have better prognosis may explain the beneficial results associated with their use in observational studies. Finally, our literature search identified only 2 small RCTs that have compared DES to BMS in vein grafts. Our meta-analysis of RCT data therefore produced inconclusive results due to wide 95% CIs. These results, combined with the inherent biases of observational studies, highlight the need for large RCTs examining the use of DES in vein grafts. In conclusion, our meta-analysis of observational studies for the use of DES in vein grafts suggests that DES may decrease MACE, mortality, TVR, and TLR compared with BMS. However, these data should be interpreted with caution due to their observational nature. Furthermore, data from the 2 small RCTs that have been conducted to date are inconclusive. There remains a need for large multicenter RCTs to address the effectiveness and safety of DES for vein graft stenosis. Appendix 1. Forest plot of observational studies that compared the effect of revascularization of vein grafts with drug-eluting stents with that of bare-metal stents on the odds of target lesion revascularization. Appendix 2. Forest plot of observational studies that compared the effect of revascularization of vein grafts with drug-eluting stents with that of bare metal stents on the odds of myocardial infarction. Appendix 3. Forest plot of RCTs that compared the effect of revascularization of vein grafts with drug-eluting stents with that of bare-metal stents on the odds of experiencing a major adverse cardiac event. Appendix 4. Forest plot of RCTs that compared the effect of revascularization of vein grafts with drug-eluting stents with that of bare-metal stents on the odds of mortality. Appendix 5. Forest plot of RCTs that compared the effect of revascularization of vein grafts with drug-eluting stents with that of bare-metal stents on the odds of target vessel revascularization. Appendix 6. Forest plot of RCTs that compared the effect of revascularization of vein grafts with drug-eluting stents with that of bare-metal stents on the odds of target lesion revascularization. Appendix 7. Forest plot of RCTs that compared the effect of revascularization of vein grafts with drug-eluting stents with that of bare metal stents on the odds of myocardial infarction. References 1. 1Farb A, Boam AB. Stent thrombosis redux—the FDA perspective. N Engl J Med. 2007;356:984–987.
CrossRef
2. 2Beohar N, Davidson CJ, Kip KE, et al. Outcomes and complications associated with off-label and untested use of drug-eluting stents. JAMA. 2007;297:1992–2000.
CrossRef
3. 3Marroquin OC, Selzer F, Mulukutla SR, et al. A comparison of bare-metal and drug-eluting stents for off-label indications. N Engl J Med. 2008;358:342–352.
CrossRef
4. 4Carlsson J, James SK, Lindbäck J, et al. Outcome of drug-eluting versus bare-metal stenting used according to on- and off-label criteria. J Am Coll Cardiol. 2009;53:1389–1398. Abstract | Full Text |
Full-Text PDF (1184 KB)
|
CrossRef
5. 5Applegate RJ, Sacrinty MT, Kutcher MA, et al. “Off-label” stent therapy 2-year comparison of drug-eluting versus bare-metal stents. J Am Coll Cardiol. 2008;51:607–614. Abstract | Full Text |
Full-Text PDF (674 KB)
|
CrossRef
6. 6Moher D, Cook DJ, Eastwood S, et al. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. 1999;354:1896–1900. Abstract | Full Text |
Full-Text PDF (86 KB)
|
CrossRef
7. 7Bax L, Yu LM, Ikeda N, et al. Development and validation of MIX: comprehensive free software for meta-analysis of causal research data. BMC Med Res Methodol. 2006;6:. 8. 8Bax L, Yu LM, Ikeda N, et al. MIX: comprehensive free software for meta-analysis of causal research data. Version 1.7. http://mix-for-meta-analysis.info2008;. 9. 9Okabe T, Lindsay J, Buch AN, et al. Drug-eluting stents versus bare metal stents for narrowing in saphenous vein grafts. Am J Cardiol. 2008;102:530–534. Abstract | Full Text |
Full-Text PDF (140 KB)
|
CrossRef
10. 10Vignali L, Saia F, Manari A, et al. Long-term outcomes with drug-eluting stents versus bare metal stents in the treatment of saphenous vein graft disease (results from the REgistro Regionale AngiopLastiche Emilia-Romagna registry). Am J Cardiol. 2008;101:947–952. Abstract | Full Text |
Full-Text PDF (553 KB)
|
CrossRef
11. 11Ellis SG, Kandzari D, Kereiakes DJ, et al. Utility of sirolimus-eluting Cypher stents to reduce 12-month target vessel revascularization in saphenous vein graft stenoses: results of a multicenter 350-patient case-control study. J Invasive Cardiol. 2007;19:404–409. 12. 12Ramana RK, Ronan A, Cohoon K, et al. Long-term clinical outcomes of real-world experience using sirolimus-eluting stents in saphenous vein graft disease. Catheter Cardiovasc Interv. 2008;71:886–893.
CrossRef
13. 13Gioia G, Benassi A, Mohendra R, et al. Lack of clinical long-term benefit with the use of a drug eluting stent compared to use of a bare metal stent in saphenous vein grafts. Catheter Cardiovasc Interv. 2008;72:13–20. 14. 14Lee MS, Shah AP, Aragon J, et al. Drug-eluting stenting is superior to bare metal stenting in saphenous vein grafts. Catheter Cardiovasc Interv. 2005;66:507–511. MEDLINE 15. 15Ge L, Iakovou I, Sangiorgi GM, et al. Treatment of saphenous vein graft lesions with drug-eluting stents: immediate and midterm outcome. J Am Coll Cardiol. 2005;45:989–994. Abstract | Full Text |
Full-Text PDF (98 KB)
|
CrossRef
16. 16Applegate RJ, Sacrinty M, Kutcher M, et al. Late outcomes of drug-eluting versus bare metal stents in saphenous vein grafts: propensity score analysis. Catheter Cardiovasc Interv. 2008;72:7–12.
CrossRef
17. 17Hoffmann R, Hamm C, Nienaber CA, et al. for the German Cypher Registry. Implantation of sirolimus-eluting stents in saphenous vein grafts is associated with high clinical follow-up event rates compared with treatment of native vessels. Coron Artery Dis. 2007;18:559–564.
CrossRef
18. 18Minutello RM, Bhagan S, Sharma A, et al. Long-term clinical benefit of sirolimus-eluting stents compared to bare metal stents in the treatment of saphenous vein graft disease. J Interv Cardiol. 2007;20:458–465.
CrossRef
19. 19Bansal D, Sachdeva R, Mehta JL. Percutaneous intervention in saphenous vein bypass graft disease: case against the use of drug-eluting stents. J Am Coll Cardiol. 2008;51:970–971. Full Text |
Full-Text PDF (218 KB)
|
CrossRef
20. 20Chu 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. Abstract | Full Text |
Full-Text PDF (94 KB)
|
CrossRef
21. 21Kaplan S, Barlis P, Kiris A, et al. Immediate procedural and long-term clinical outcomes following drug-eluting stent implantation to ostial saphenous vein graft lesions. Acute Card Care. 2008;10:88–92.
CrossRef
22. 22Jeger RV, Schneiter S, Kaiser C, et al. Drug-eluting stents compared with bare metal stents improve late outcome after saphenous vein graft but not after large native vessel interventions. Cardiology. 2009;112:49–55. 23. 23Wöhrle J, Nusser T, Kestler HA, et al. Comparison of the slow-release polymer-based paclitaxel-eluting Taxus-Express stent with the bare-metal Express stent for saphenous vein graft interventions. Clin Res Cardiol. 2007;96:70–76.
CrossRef
24. 24Lozano I, García-Camarero T, Carrillo P, et al. Comparison of drug-eluting and bare metal stents in saphenous vein grafts. Immediate and long-term results. Rev Esp Cardiol. 2009;62:39–47. 25. 25Assali A, Raz Y, Vaknin-Assa H, et al. Beneficial 2-years results of drug-eluting stents in saphenous vein graft lesions. EuroIntervention. 2008;4:108–114. 26. 26van Twisk PH, Daemen J, Kukreja N, et al. Four-year safety and efficacy of the unrestricted use of sirolimus- and paclitaxel-eluting stents in coronary artery bypass grafts. EuroIntervention. 2008;4:311–317. 27. 27Vermeersch 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 | Full Text |
Full-Text PDF (205 KB)
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28. 28Brilakis ES, Lichtenwalter C, de Lemos JA, et al. A randomized controlled trial of a paclitaxel-eluting stent versus a similar bare-metal stent in saphenous vein graft lesions the SOS (Stenting of Saphenous Vein Grafts) trial. J Am Coll Cardiol. 2009;53:919–928. Abstract | Full Text |
Full-Text PDF (972 KB)
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CrossRef
29. 29Sarjeant JM, Rabinovitch M. Understanding and treating vein graft atherosclerosis. Cardiov Pathology. 2002;11:263–271. 30. 30Ratliff NB, Myles JL. Rapidly progressive atherosclerosis in aortocoronary saphenous vein grafts. Possible immune-mediated disease. Arch Pathol Lab Med. 1989;113:772–776. MEDLINE 31. 31Cross KS, Davies MG, el Sanadiki MN, et al. Long-term human vein graft contractility and morphology: a functional and histopathological study of retrieved coronary vein grafts. Br J Surg. 1994;81:699–705. MEDLINE |
CrossRef
32. 32AV Sterpetti A, Cucina B, Randone R, et al. Growth factor production by arterial and vein grafts: relevance to coronary artery bypass grafting. Surgery. 1996;120:460–467. Abstract |
Full-Text PDF (3288 KB)
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33. 33Ge L, Iakovou I, Cosgrave J, et al. Immediate and mid-term outcomes of sirolimus-eluting stent implantation for chronic total occlusions. Eur Heart J. 2005;26:1056–1062.
CrossRef
34. 34Commeau P, Barragan PT, Roquebert PO, et al. ISR II study: a long-term evaluation of sirolimus-eluting stent in the treatment of patients with in-stent restenotic native coronary artery lesions. Catheter Cardiovasc Interv. 2005;66:158–162. MEDLINE |
CrossRef
35. 35Vermeersch P, Agostoni P, Verheye S, et al. Randomized double-blind comparison of sirolimus-eluting stent versus bare-metal stent implantation in diseased saphenous vein grafts: six-month angiographic, intravascular ultrasound, and clinical follow-up of the RRISC Trial. J Am Coll Cardiol. 2006;48:2423–2431. Abstract | Full Text |
Full-Text PDF (154 KB)
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a Division of Cardiology, Jewish General Hospital, Montreal, Quebec, Canada b Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada c Division of Clinical Epidemiology, McGill University Health Center, Montreal, Quebec, Canada d Division of Clinical Epidemiology, Jewish General Hospital, Montreal, Quebec, Canada  Reprint requests: Mark J. Eisenberg, MD, MPH, FACC, FAHA, Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University, 3755 Cote Ste. Catherine Rd/Suite A-118, Montreal, Quebec, Canada H3T 1E2.
Dr Eisenberg is a Chercheur-National of the Fonds de la Recherche en Santé du Quebec. Dr Filion received financial support from the Faculty of Medicine of McGill University, the Research Institute of the McGill University Health Centre, and the Department of Medicine of the McGill University Health Center. Conflict of interest/disclosure: none. PII: S0002-8703(09)00901-6 doi:10.1016/j.ahj.2009.11.021 © 2010 Mosby, Inc. All rights reserved. | |
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