Chronic stable angina revascularization percutaneous coronary intervention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [4]; John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Percutaneous coronary intervention for coronary artery disease first began in 1977, as a valuable mode of revascularization, wherein at the point of coronary stenosis a catheter-borne balloon is inflated to relieve the stenosis. The advantages of PCI for the treatment of CAD are many and include a low level of procedure-related morbidity and mortality rate in properly selected patients, a shorter hospital stay, early return to activity, and the feasibility of multiple procedures. The risk of acute coronary occlusion during PCI and increased incidence of restenosis in lesions that were successfully treated limits the use of PCI.[1][2]

Ideal candidates for PTCA/PCI include patients with stable angina less than 75 years of age, with single-vessel and/or single-lesion CAD, without a history of diabetes. Objective large ischemia, in particular, lesions less than 10 mm, readily accessible, concentric, and discrete are best suited for revascularization by PCI. On the contrary, chronic total occlusions that cannot be crossed, lesions greater than 20 mm, tortuous, irregular, angulated, calcified, severely stenotic with one or more lesion greater than 90% stenosis present in an artery are associated with an increased risk of morbidity and mortality from the procedure. In addition, PCI is used with reservation in diabetics with multi-vessel disease and in patients with unprotected left main stenosis. Other important factors include the operator volume and the presence or absence of onsite cardiovascular surgeon.[3]

Primary success of coronary intervention is generally defined as an absolute increase of 20% points in the luminal diameter and a final diameter obstruction of less than 30%. Such angiographic success can be anticipated in more than 90% of properly selected patients.

Over the years, alternative methods of percutaneous treatment developed include the use of intracoronary brachytherapy for in-stent restenosis,[4][5] cutting balloon with metal razors to avoid the spillage and subsequent reduction in the incidence of vessel trauma, burr rotablation that pulverizes the atheromatous material[6] and intracoronary stents designed to maintain the lumen size.

Indications

  • PCI has been shown to reduce the frequency of anginal symptoms and improve exercise tolerance in patients with single and double-vessel coronary artery disease.
  • In the ACME trial, approximately 213 patients with stable single-vessel CAD were assessed to compare the effects of PCI with medical therapy on angina and exercise tolerance. The study demonstrated that PCI offered earlier and more complete relief of angina than medical therapy (64% patients in PCI group versus 46% medically treated group; p=less than 0.01) and was associated with a better exercise tolerance (2.1 in the PCI group versus 0.5 minutes in the medically treated group; p=less than 0.0001) as observed at 6-month follow-up.[7]
  • In a sub-study that assessed the long-term effectiveness of PCI for single-vessel CAD, demonstrated sustained benefits with PCI similar to the ACME trial, hence making it an attractive therapeutic option.[8]
  • In patients with objective large ischemia associated with severe angina, PCI has shown to significantly reduce mortality and provide greater symptomatic improvement. However, on the contrary, patients with mild symptoms do not benefit from PCI.
  • In the ACIP study, that compared the 12-week efficacy of the three treatment strategies such as medical therapy, medical therapy plus ambulatory ECG monitoring or revascularization to suppress cardiac ischemia, and to assess the feasibility of a prognosis trial in patients with asymptomatic cardiac ischemia, demonstrated both stress-inducible ischemia and two or more ischemic episodes on holter monitoring.[9] Two years after randomization, the total mortality was significantly reduced from 6.6% in the angina-guided strategy to 4.4% in the ischemia-guided strategy and 1.1% in the revascularization strategy (p=less than 0.02). The rate of composite primary end-points was also significantly reduced from 41.8% in the angina-guided strategy to 38.5% in the ischemia-guided strategy and 23.1% in the revascularization strategy (p=less than 0.001).[10]
  • The RITA-2 trial compared the long-term effects of PCI and conventional medical therapy in patients with CAD, demonstrated an early intervention with PCI was associated with greater symptomatic improvement, particularly observed in patients with more severe angina. However, on the contrary, the primary composite end-points during a median 2.7 year follow-up was significantly higher in patients treated with PCI than in patients treated with medical therapy (6.3% in the PCI group versus 3.3% in the medically treated group; p=0.02).[11]
  • In the TIME study, that assessed the long-term survival and quality of life in elderly patients with CCS class II or greater angina receiving atleast two anti-anginal medication at baseline, demonstrated similar long-term survival benefits observed in both the groups; however, freedom from major cardiovascular events remained higher in invasive therapy group versus the medical therapy group (39% versus 20%, p=less than 0.0001). Irrespective of whether patients were catheterized initially or only after failure to respond to medical therapy, their survival rates were better if they were revascularized within the first year.[15]
  • The GISSOC trial, studied the benefit of stent implantation over balloon PTCA for the treatment of chronic total coronary occlusions. The study demonstrated a significant reduction in the major adverse cardiovascular events observed in the stent group during a 6-year follow-up (76.1% in the stent group versus 60.4% in the PTCA group; p=0.055) and attributed this reduction secondary to the target lesion revascularization free-survival rate (85.1% in the stent group versus 65.5% in the PTCA group; p=0.0165). However, in most cases, restenosis of the study occlusion was evident at nine-month angiography. Thus, the study concluded stent implantation was superior to balloon PTCA in chronic total occlusions that can be recanalized percutaneously and is a valuable long-term therapeutic option; however, at nine-month follow-up both the stent and PTCA results appear to remain stable.[16]
  • Similar benefits with stent implantation for chronic total occlusion were reported in few other studies such as:
  • The PRISON study, that demonstrated a statistically significant reduction in the need for target lesion revascularization (29% in the PTCA group versus 13% in the stent group; p=less than 0.0001) and a non-significant rate of restenosis was observed (33% in the PTCA group versus 22% in the stent group; p=0.137).[17]
  • The STOP study, demonstrated significant reduction in the rate of restenosis (42.1% in the stent group versus 70.9% in the PTCA group; p=0.034) and reocclusion (7.9% in the stent group versus 16.1% in the PTCA group) observed with the stent implantation. However, stent group was associated with more a diffuse in-stent restenosis in comparison to a focal re-stenosis in the PTCA group that occurred at the point of total obstruction (within 5mm).[18]
  • The SARECCO trial, demonstrated a significant event free survival in the stent group observed during a 2-year follow-up (26% in the group that received angioplasty alone versus 52% in the stent group; p=less than 0.05).[19]
  • The SPACTO trial, demonstrated significant reduction in the rates of restenosis (29% in the stent group versus 72% in the PTCA group; p=less than 0.01) and reocclusion (3% in the stent group versus 24% in the PTCA group) observed in the stent group. At follow-up,there was also a significant reduction in cardiac events (p=less than 0.03) and marked improvement in the anginal class (p=less than 0.01) reported in the stent group.[20]
  • The TOSCA study, demonstrated stent implantation significantly improved late patency and reduced the rates of restenosis (70% in the PTCA group versus 55% in the stent group; p=less than 0.01) and target-vessel revascularization (15.4% in the PTCA group versus 8.4% in the stent group; p=0.03). Hence, the study concluded stent implantation being superior to PTCA for non-acute coronary occlusions.[21]
  • The SICCO trial, reported a significant reduction in the target lesion revascularization (22% in the stent group versus 42% in the PTCA group; p=0.025) and restenosis (32% patients with stent and 74% patients with PTCA only; p=0.025) noted in the stent implantation group.[22]
  • In the PACTO study, 48 consecutive patients received paclitaxel-eluting stent implantation after successful recanalization of a chronic total occlusion, to assess the efficacy of drug-eluting stent in comparison to bare metal stent for the treatment of chronic total coronary occlusions. At 1-year follow-up, the incidence of major adverse cardiovascular events was significantly reduced in the paclitaxel group (12.5% in the Taxus group and 47.9% in the BMS group; p=less than 0.001) which was secondary to reduced need for repeat revascularization. The secondary end-points included the rate of restenosis (8.3% in the Taxus group and 51.1% in the BMS group; p=less than 0.001) and reocclusion (2.1% in the Taxus group and 23.4% in the BMS group; p=less than 0.005) which was also significantly reduced in the paclitaxel group. Thus, the study concluded, paclitaxel-eluting stent drastically reduced the incidence of major cardiovascular events and restenosis, and almost eliminated reocclusion which is frequently observed with bare metal stents when used for chronic total occlusion.[23]
  • The AWESOME trial and registry, demonstrated the benefit of PCI over CABG in patients with refractory ischemia and who are at increased risk of adverse events, which may also be applicable to patients with left ventricular dysfunction.[24][25]
  • In a sub-study of patients with prior CABG, the three-year survival rate between CABG and PCI groups did not differ significantly: 73% in the CABG group and 76% in the PCI group (p=NS). However, the patient choice registry, reported that the patients with prior-CABG preferred PCI over repeat CABG.[26]

Drug eluting stents in PCI

A recent update on drug-eluting stents, reported similar success rates and side effects associated with both the Cypher (sirolimus eluting) and TAXUS (paclitaxel eluting) stents. Hence, a similar benefit may be replicated in routine clinical practice.[30][31]

Paclitaxel-eluting stent studies

The clinical outcome with the use of paclitaxel depends on whether it is a polymer-based or not.[32] Based on the results of the DELIVER-I study, paclitaxel without a polymer carrier did not demonstrate a positive clinical outcome despite an improvement noted in the angiographic parameters. However, on the contrary a polymer-based paclitaxel significantly improved clinical outcomes demonstrated by the TAXUS-IV and TAXUS-VI trials.

  • The DELIVER trial demonstrated a significant reduction only in the angiographic late lumen loss (0.81 versus 0.98; p=0.003) at follow-up with non-polymer-based paclitaxel-coated stent compared to bare metal stent respectively among 1043 patients with focal denovo coronary lesions. Thus, the study concluded paclitaxel-coated stent decreased the neointimal proliferation compared with the bare-metal stent; however, this reduction was insufficient to meet the prespecified primary end-point of target-vessel failure (11.9% in the polymer-coated stent group versus 14.5% in the bare metal stent group; p=0.12) and the secondary end point of binary restenosis (14.9% in the polymer-coated stent group versus 20.6% in the bare metal stent group; p=0.076).[33]
  • In the TAXUS-IV trial, 1314 patients who were receiving a stent in a single, previously untreated coronary artery stenosis with a mean vessel diameter of 2.75 mm and a mean lesion length of 13.4 mm at baseline, were randomized to receive either a bare-metal stent (n=652) or a slow-release polymer-based, paclitaxel-eluting stent (n=662), to assess the incidence of neointimal hyperplasia and restenosis with paclitaxel. At 9-month follow-up, a significant reduction in the rate of ischemia-driven target-vessel (12% in the BMS group versus 4.7% in the TAXUS group; relative risk 0.39; 95% CI, 0.26 to 0.59; p=less than 0.001), target-lesion revascularization (11.3% in the BMS group versus 3% in the TAXUS group; relative risk 0.27; 95% CI, 0.16 to 0.43; p=less than 0.001) and the rate of angiographic restenosis (26.6% in the BMS group versus 7.9% in the TAXUS group; relative risk 0.30; 95% CI, 0.19 to 0.46; p=less than 0.001) was observed in the TAXUS group. However, the rate of all cause of mortality including MI (4.7% in the BMS goup and 4.3% in the TAXUS group; p=NS) and stent thrombosis (0.6% in the BMS goup and 0.8% in the TAXUS group; p=NS) during a 9-month follow-up did not differ between the two groups. Thus, the study concluded in comparison with bare-metal stents, the slow-release, polymer-based, paclitaxel-eluting stent is safe and markedly reduced the rates of clinical and angiographic restenosis at nine months.[34]
  • In the TAXUS-VI trial, 448 patients with long, complex coronary artery lesions were randomized to receive either a drug-eluting TAXUS Express-2 stent or an uncoated Express-2 control stent, to assess the efficacy of paclitaxel-eluting stent in the treatment of complex coronary stenoses with a mean lesion length of 20.6mm at baseline. At 9-month follow-up, a significant 53% reduction of target-vessel revascularization (9.1% in the TAXUS group and 19.4% in the control group; p=0.0027) and a significant reduction from 32.9% in the control group to 9.1% in the TAXUS for the binary restenosis at the stented area was observed in the TAXUS group (p=less than 0.0001). However, the incidence of major adverse cardiac events at 9-month follow-up, was similar among both the groups: 16.4% in TAXUS and 22.5% in the control group (p=NS). Thus, the study concluded that the TAXUS Moderate Release stent system is safe and effective in the treatment of long, complex coronary artery lesions; hence, providing the evidence base for more widespread use of drug-eluting stents in contemporary clinical practice.[35]
  • Clinical follow-up at 2 years post-stenting was available in 98.6% of the TAXUS group and 95.6% of the control group. The incidence of major adverse cardiac event at one- and two-year follow-up was 16.4% and 21.3% in the TAXUS group when compared with 22.5 and 25.1% in the control group, respectively. A significant difference in the target-vessel revascularization was maintained at two-year follow-up (TAXUS 13.9%; control 21.9%; P=0.0335). There was also a significant reduction in the cumulative one- and two-year survival rates free from target-vessel revascularization (91.7 and 90.3% in the TAXUS group versus 80.0 and 79.0% in the control group; p=less than 0.001).[36]
  • At 5-year follow-up, the overall rate of major adverse cardiac events was found to be similar among both the groups (27.8% in control and 31.3% in TAXUS; p=0.61), including similar rates for stent thrombosis, target-vessel revascularization (23.7% in control and 22.2% in TAXUS; P=0.45). Thus, the study concluded since the TAXUS MR stent demonstrated similar rates of target-vessel revascularization, incidence of major cardiac event and reduced the rate of target-lesion revascularization in comparison to the control through five years, it is may be beneficial to use paclitaxel-eluting TAXUS moderate-release for long, complex coronary artery lesions. However, the cause for the increased rate of non-target lesion revascularization (5.1% in control and 10.9% in TAXUS; p=0.0274) associated with TAXUS remains unclear.[37]

Sirolimus-eluting stent studies

In contrary to the paclitaxel-eluting stent studies, the trials that assessed the effect of sirolimus have tested only the polymer-based sirolimus-eluting stent.

  • In the SIRIUS study, 1058 patients with complex coronary artery disease due to the presence of diabetes, mean lesion length of 14.4 mm and a mean vessel diameter of 2.80 mm at baseline, were randomized to receive either a sirolimus-eluting stent or a standard stent to evaluate the effect of sirolimus in the reduction of restenosis after PCI. At 9-month follow-up, a significant reduction in the frequency of neointimal hyperplasia within the stent was observed with the sirolimus-eluting stents, as assessed by both angiography and intravascular ultrasonography. Subgroup analyses revealed a significant reduction in the rates of angiographic restenosis and target-lesion revascularization in all subgroups examined. Thus, the study concluded that sirolimus-eluting stent provided beneficial results in patients with complex coronary lesions and also significantly reduced the rate of neointimal proliferation, restenosis and associated clinical events.[38][39]
  • In the SIRIUS trial, 459 with an LAD stenosis and a mean length of 14.0mm at baseline, were randomized to percutaneous intervention with either sirolimus-eluting stent or bare-metal stents, to evaluate the benefit of drug-eluting stent secondary to the reduction of restenosis rate in the management of LAD stenosis. The study reported a significant reduction in the rate of binary in-stent restenosis in the SES group (2% in the SES group versus 41.6% in the BMS group; RR 0.05; p=less than 0.001). A significant 59% reduction in the one-year major adverse events including death, MI or target vessel revascularization was noted in the SMS group (9.8% SMS group versus 24.9% BMS; RR 0.39; p=less than 0.001). Thus, the study concluded for LAD stenosis, the revascularization rate with sirolimus-eluting stent was similar to that of the single vessel bypass surgery at one-year.[40]
  • Both the RESEARCH registry and the Swiss registry demonstrated significant benefit with the use of sirolimus in routine clinical practice. The RESEARCH registry reported a significant reduction in the rate of target-vessel revascularization for sirolimus group (3.7% in the sirolimus versus 10.9% in the BMS; p=less than 0.001).[41] The Swiss registry also demonstrated a 95.6% significant event-free survival noted in the sirolimus group as observed during a 6-9 month follow-up.[42]
  • The Cypher stent registry, demonstrated similar benefits such as survival-free of major adverse cardiac event (96.4% in the SES group versus 82.8% in the BMS group; p=less than 0.05) and significant reduction in the rate of restenosis observed with the use of sirolimus-eluting stent for the treatment chronic total coronary obstruction.[43]

Complications of percutaneous coronary intervention

The improvements in devices, the use of stents, and aggressive antiplatelet therapy have significantly reduced the incidence of major procedural complications of PCI over the past 2 decades despite the increasing complexity of cases. However, as with any invasive procedure, complications can occur. The major complications of PTCA/PCI include coronary artery dissection and acute closure, intramural hematoma, coronary artery perforation, and occlusion of branch vessels: Dissections are found in up to 50 percent of patients immediately after PTCA. Intimal tears or dissections following PTCA have been arbitrarily divided into types A to F.

  • Type A — Luminal haziness
  • Type B — Linear dissection
  • Type C — Extraluminal contrast staining
  • Type D — Spiral dissection
  • Type E — Dissection with reduced flow
  • Type F — Dissection with total occlusion

These problems are now much less frequent since stent placement is performed in most percutaneous coronary procedures. Abrupt closure is most often due to arterial dissection and is manifested as acute ischemic chest pain and ECG changes. The incidence of abrupt closure with conventional balloon angioplasty (PTCA) is approximately 5% and is associated with a 10-fold increase in mortality to about 1 percent and nonfatal MI. The frequency of this complication, however, has now been greatly reduced by pretreatment with the platelet glycoprotein IIb/IIIa receptor blockers and by the insertion of an intracoronary stent. If stenting does not restore adequate flow, emergency CABG can be performed.

Coronary artery intramural hematoma is defined as an accumulation of blood within the medial space displacing the internal elastic membrane inward and the external elastic membrane outward, with or without identifiable entry and exit points. It is identified in 6.7 percent of procedures by intravascular ultrasound (IVUS).

Coronary artery perforation in the stent era is a rare but potentially disastrous complication.

Downstream embolization of thrombus or plaque contents with microvascular obstruction is common after PCI and occlusion of side branches has been reported in up to 19 percent of cases in which a stent was placed across a major side branch.

Stent thrombosis is catastrophic complication that usually leads to death or ST segment elevation MI. It is therefore a medical emergency. Stent thrombosis can occur acutely (during or soon after the PCI), subacutely (within 30 days after stent placement), or as a complication. Late stent thrombosis is associated with the cessation of aspirin or clopidogrel therapy. On the other hand, very late stent thrombosis, occurring after one year, is associated with drug-eluting stents.

Restenosis is the result of arterial damage with subsequent neointimal tissue proliferation. It is usually defined as a greater than 50% diameter stenosis. The incidence of angiographic restenosis is approximately 30% to 40% after PTCA. Intracoronary stents reduce the rate of angiographic and clinical restenosis and post-procedural myocardial infarction compared to percutaneous transluminal coronary angioplasty (PTCA) alone. Trials have demonstrated that the sirolimus and paclitaxel drug-eluting stents markedly reduced the incidence of in-stent restenosis and the rate of target lesion revascularization compared to bare metal stents. As a result, stents are currently utilized in nearly all percutaneous coronary interventions. However, the benefits of drug-eluting stents on restenosis must be weighed against rates of stent thrombosis, which often leads to death or MI, if dual antiplatelet therapy is prematurely discontinued. Restenosis occurs more frequently in diabetics, smaller arteries, among total occlusions, and in left anterior descending arteries, particularly proximal lesions. Since not all angiographic restenosis results in recurrent symptoms, the rates of clinical restenosis are lower than these angiographic estimates. Recurrent sever angina occurs in approximately half of the patients who develop angiographic restenosis and usually responds to stenting. In symptomatic patients with BMS restenosis, a repeat stenting using a DES is usually recommended. In symptomatic patients with intracoronary DES restenosis, there are insufficient data to suggest any specific treatment.

ACC/AHA Guidelines- Revascularization With PTCA (or Other Catheter-Based Techniques) and CABG (DO NOT EDIT) [44]

“

Class I

1. PTCA for patients with two- or three-vessel disease with significant proximal left anterior descending CAD, who have anatomy suitable for catheter-based therapy, normal LV function, and who do not have treated diabetes. (Level of Evidence: B)

2. PTCA or CABG for patients with one- or two-vessel CAD without significant proximal left anterior descending CAD but with a large area of viable myocardium and high-risk criteria on noninvasive testing. (Level of Evidence: B)

3. In patients with prior PTCA, CABG or PTCA for recurrent stenosis associated with a large area of viable myocardium and/or high-risk criteria on noninvasive testing. (Level of Evidence: C)

4. PTCA or CABG for patients who have not been successfully treated by medical therapy and can undergo revascularization with acceptable risk. (Level of Evidence: B)

Class IIa

1. Repeat CABG for patients with multiple saphenous vein graft stenoses, especially when there is significant stenosis of a graft supplying the left anterior descending coronary artery. PTCA may be appropriate for focal saphenous vein graft lesions or multiple stenoses in poor candidates for re-operative surgery. (Level of Evidence: C)

2. PTCA or CABG for patients with one- or two-vessel CAD without significant proximal left anterior descending CAD but with a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing. (Level of Evidence: B)

3. PTCA or CABG for patients with one-vessel disease with significant proximal left anterior descending0 CAD. (Level of Evidence: B)

Class IIb

1. Compared with CABG, PTCA for patients with two- or three-vessel disease with significant proximal left anterior descending CAD who have anatomy suitable for catheter-based therapy and who have treated diabetes or abnormal LV function. (Level of Evidence: B)

2. PTCA for patients with significant left main coronary disease who are not candidates for CABG. (Level of Evidence: C)

3. PTCA for patients with one- or two-vessel CAD without significant proximal left anterior descending CAD who have survived sudden cardiac death or sustained ventricular tachycardia. (Level of Evidence: C)

Class III

1. PTCA or CABG for patients with one- or two-vessel CAD without significant proximal left anterior descending CAD who have mild symptoms that are unlikely due to myocardial ischemia or have not received an adequate trial of medical therapy and

a. Have only a small area of viable myocardium or
b. Have no demonstrable ischemia on noninvasive testing. (Level of Evidence: C)

2. PTCA or CABG for patients with borderline coronary stenoses (50% to 60% diameter in locations other than the left main) and no demonstrable ischemia on noninvasive testing. (Level of Evidence: C)

3. PTCA or CABG for patients with insignificant coronary stenosis (less than 50% diameter). (Level of Evidence: C)

4. PTCA in patients with significant left main CAD who are candidates for CABG. (Level of Evidence: B)

”

ESC Guidelines- Revascularization to improve prognosis (DO NOT EDIT) [45]

“

Class IIa

1. PCI or CABG for patients with reversible ischaemia on functional testing and evidence of frequent episodes of ischaemia during daily activities. (Level of Evidence: C)

”

ESC Guidelines- Revascularization to improve symptoms (DO NOT EDIT) [45]

“

Class I

1. PCI for one-vessel disease technically suitable for percutaneous revascularization in patients with moderate-to-severe symptoms not controlled by medical therapy, in whom procedural risks do not outweigh potential benefits. (Level of Evidence: A)

2. PCI for multi-vessel disease without high-risk coronary anatomy, technically suitable for percutaneous revascularization in patients with moderate-to-severe symptoms not controlled by medical therapy, in whom procedural risks do not outweigh potential benefits. (Level of Evidence: A)

Class IIa

1. PCI for one-vessel disease technically suitable for percutaneous revascularization in patients with mild-to-moderate symptoms which are nonetheless unacceptable to the patient, in whom procedural risks do not outweigh potential benefits. (Level of Evidence: A)

2. PCI for multi-vessel disease technically suitable for percutaneous revascularization in patients with mild-to-moderate symptoms which are nonetheless unacceptable to the patient, in whom procedural risks do not outweigh potential benefits. (Level of Evidence: A)

”

Vote on and Suggest Revisions to the Current Guidelines

Sources

  • The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [44]
  • Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [45]
  • TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [46]
  • The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [47]

References

  1. ↑ Bauters C, Banos JL, Van Belle E, Mc Fadden EP, Lablanche JM, Bertrand ME (1998) Six-month angiographic outcome after successful repeat percutaneous intervention for in-stent restenosis. Circulation 97 (4):318-21. PMID: 9468204
  2. ↑ Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF et al. (1999) Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome. Circulation 100 (18):1872-8. PMID: 10545431
  3. ↑ Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB et al. (2006) ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation 113 (1):156-75. DOI:10.1161/CIRCULATIONAHA.105.170815 PMID: 16391169
  4. ↑ Teirstein PS, Massullo V, Jani S, Popma JJ, Russo RJ, Schatz RA et al. (2000) Three-year clinical and angiographic follow-up after intracoronary radiation : results of a randomized clinical trial. Circulation 101 (4):360-5. PMID: 10653825
  5. ↑ Salomon R, Soreq H, Givon D, Sela I, Littauer UZ (1975) Proceedings: Enzymatic acylation of histidine to tobacco mosaic virus RNA. Isr J Med Sci 11 (11):1208-9. PMID: 1205798
  6. ↑ Kobayashi Y, Teirstein P, Linnemeier T, Stone G, Leon M, Moses J (2001) Rotational atherectomy (stentablation) in a lesion with stent underexpansion due to heavily calcified plaque. Catheter Cardiovasc Interv 52 (2):208-11. PMID: 11170330
  7. ↑ Parisi AF, Folland ED, Hartigan P (1992) A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators. N Engl J Med 326 (1):10-6. DOI:10.1056/NEJM199201023260102 PMID: 1345754
  8. ↑ Hartigan PM, Giacomini JC, Folland ED, Parisi AF (1998) Two- to three-year follow-up of patients with single-vessel coronary artery disease randomized to PTCA or medical therapy (results of a VA cooperative study). Veterans Affairs Cooperative Studies Program ACME Investigators. Angioplasty Compared to Medicine. Am J Cardiol 82 (12):1445-50. PMID: 9874045
  9. ↑ Pepine CJ, Geller NL, Knatterud GL, Bourassa MG, Chaitman BR, Davies RF et al. (1994) The Asymptomatic Cardiac Ischemia Pilot (ACIP) study: design of a randomized clinical trial, baseline data and implications for a long-term outcome trial. J Am Coll Cardiol 24 (1):1-10. PMID: 8006249
  10. ↑ Davies RF, Goldberg AD, Forman S, Pepine CJ, Knatterud GL, Geller N et al. (1997) Asymptomatic Cardiac Ischemia Pilot (ACIP) study two-year follow-up: outcomes of patients randomized to initial strategies of medical therapy versus revascularization. Circulation 95 (8):2037-43. PMID: 9133513
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