Complex Lesions
The challenges presented by different types of complex lesions in PCI are summarized in the figure below. One of reasons that complex lesions are considered challenging is that they increase the risk of thrombus formation and distal embolization. They do this in two ways: disrupted blood flow and exposure to thrombogenic material. From a procedural perspective, they can be more technically challenging for the physician.
Complex lesions are a challenge in PCI, as evidenced by the following facts:
- Complex lesion patients exhibit intracoronary thrombus (ICT) more frequently than simple lesion patients (58%–68% versus 28%).1
- There is a greater risk of adverse events and complications. 2
- Complex lesion patients have a higher risk of 6-month restenosis (33.2% versus 24.9% with simple lesions; P<0.001).
- One-year event-free survival is 75.6% for complex lesions and 81.1% in patients with simple lesions (P<0.001).
- Complex lesions predispose to higher in-hospital (P<0.001) and 1-year (P<0.001) rates of death, death/MI, and death/MI/CABG than simple lesions.
ReoPro reduces in-lab PCI complications
Abciximab significantly reduced the incidence of angiographic complications during coronary stenting by 29% (P = 0.001) when compared with placebo in all patients in the EPISTENT trial.Angiographic Complications |
Placebo |
Abciximab |
P value |
|---|---|---|---|
Any angiographic complication |
191 (23.8%) |
133 (17.0%) |
0.001 |
Major or minor coronary dissection |
133 (16.6%) |
94 (12.0%) |
0.009 |
Final TIMI flow <3 |
36 (16.6%) |
19 (2.5%) |
0.024 |
Any vessel occlusion |
41 (5.1%) |
20 (2.6%) |
0.008 |
Side branch occlusion |
36 (4.5%) |
19 (2.4%) |
0.025 |
Other vessel occlusion |
5 (0.6%) |
1 (0.1%) |
0.218* |
Transient coronary occlusion |
19 (2.4%) |
11 (1.4%) |
0.159 |
Residual stenosis >50% |
12 (1.5%) |
6 (0.8%) |
0.170 |
Referred for urgent coronary |
4 (0.5%) |
5 (0.6.%) |
0.750* |
Thrombus postintervention |
12 (1.5%) |
11 (1.4%) |
0.879 |
Distal embolization |
10(1.2%) |
10 (1.3%) |
0.957 |
Localized perforation |
2 (0.2%) |
2 (0.3%) |
1.0* |
*Fisher's exact test used
The primary endpoint of the EPISTENT trial was death, MI, or urgent intervention at 30 days (ReoPro + stent 10.8%, P<.001, relative reduction 51%; ReoPro + baloon 6.9%, placebo + stent 10.8%, P=.007, relative reduction 36%)4
ReoPro improves long-term outcomes
One year outcomes"...patients with complex or non-STRESS/BENESTENT-like lesions have a pronounced benefit from the use of stents with adjunctive abciximab with respect to death, MI, and TVR."5
For one year mortality, there was a considerable overall reduction amoung patients assigned to stent and ReoPro compared to stent alone, balloon alone or balloon + ReoPro.
The primary endpoint of the EPILOG trial was death, MI, or urgent revascularization at 30 days (ReoPro + low-dose heparin 5.2%, placebo + standard-dose heparin 11.7%, P<.001, relative reduction 56%; ReoPro + standard-dose heparin 5.4%, placebo + standard-dose heparin 11.7%, P<.001, relative reduction 54%)6
The primary endpoint of the EPISTENT trial was death, MI, or urgent intervention at 30 days (ReoPro + stent 5.3%, placebo + stent 10.8%, P.001, relative reduction 51%; ReoPro + balloon 6.9%, placebo + stent 10.8%, P=.007, relative reduction 36%)4
Data from earlier studies with balloon angioplasty were not suggestive of the same mortality benefit.
- White JC, Ramee SR, Collins TJ, et al. Coronary thrombi increase PTCA risk. Angioscopy as a clinical tool. Circulation. 1996;93(2):253-258.
- Internal Marketing Research, ReoPro White Paper
- Islam MA, et al. Am J Cardiol. 2002;90:916-921.
- The EPISTENT Investigators. Lancet. 1998;352:87-92.
- The EPILOG Investigators. N Engl J Med. 1997;336:1689-96.
- Cura FA, et al. Circulation. 2000;102:32-33.
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