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Several studies and meta-analysis have shown that direct stenting (DS) may improve clinical outcomes and reduce the incidences of no-reflow in patients with acute ST-elevation myocardial infarction (STEMI). Totally occluded culprit arteries in patients with STEMI are associated with worse short- and long-term outcomes. Probably, DS in these patients can prevent distal embolization and improve outcomes. Thus, the aim of this study is to evaluate in-hospital outcomes of DS compare with stenting after predilation (PD) and manual thrombus aspiration (TA) in STEMI patients with totally occluded culprit artery.
Data were collected from all patients (n = 1297) with STEMI admitted to the coronary care unit and submitted to percutaneous coronary interventions (PCI) from 2006 to 2015. A total of 841 patients (61.4%) with totally occluded culprit arteries (TIMI flow grade 0) were included in the analysis. DS was performed in cases when the culprit vessel was visualized (at least TIMI flow grade 1) after wiring. The clinical and angiographic characteristics, in-hospital outcomes, as well as predictors of angiographic no-reflow were analyzed. The composite of in-hospital death, recurrent myocardial infarction and stent thrombosis were defined as major adverse cardiac events (MACE). Propensity score adjustment was used to reduce imbalances in covariates at baseline.
Two hundred and ninety-four (35%) patients received DS were compared with 547 (65%) patients received non-DS. Among non-DS group were 478 (87.4%) patients received stenting after PD, 31 patients received (5.7%) TA and 38 (6.9%) patients received stenting after combination of PD and TA. Patients of DS group were younger (58±11vs 60±12 years), they rarely had a history of previous PCI (5.8% vs 11.3%, p=0.008). In DS group the infarct-related artery was RCA more often (48% vs 34.4%, p<0.001), while in non-DS group LAD (34.7% vs 48.4%, p<0.001). The rates of male, diabetes mellitus, hypertension, previous myocardial infarction, and multivessel disease were comparable between groups. There were no difference in rates of stent thrombosis (1.4% vs 1.3%; p=0.78) and recurrent myocardial infarction (0.7% vs 1.8%; p=0.32). The rates of death (3.1% vs 6.2%; p=0.006), MACE (4.4% vs 8.2%; p=0.004), and angiographic no-reflow (2.7% vs 9.9%; p<0.001) were significantly lower in the DS group. After multivariate adjustment, non-DS strategy remained an independent predictor of no-reflow (odds ratio (OR) 5.9; 95% confidence interval (CI) 2.9-12; p<0.01) along with blood glucose level (OR 1.1; 95% CI 1.06-1.2; p<0.001). Following propensity score matching, each group contained 293 patients. There were no significant differences between the two groups in baseline characteristics. The rates of MACE (4.4% vs 8.5%; p=0.04) and angiographic no-reflow (2.7% vs 9.6%; p<0.001) remains significantly lower in DS group.
Direct stenting strategy in STEMI patients with totally occluded culprit arteries is associated with better clinical and procedural outcomes. Direct stenting is a safe and feasible technique and should be applied in all cases when possible.
CORONARY: Acute Myocardial Infarction