NEW YORK (Reuters Health) – Using a distal filter to protect against emboli during coronary stent implantation increases long-term rates of stent thrombosis and target vessel revascularization, investigators in Denmark report.
Randomized trials have shown no benefit of distal protection in the short or intermediate term after percutaneous coronary intervention (PCI), Dr. Anne Kaltoft from Aarhus University Hospital, Skejby, and her associates note. Their article in the Journal of the American College of Cardiology for March 2 reports their 15-month follow-up of patients treated for ST-elevation myocardial infarction in the DEDICATION trial.
Patients received aspirin, clopidogrel, and unfractionated heparin in advance of the procedure. If a cardiologist believed that a wire filter could be advanced (based on pre-dilation and initial visualization of the peripheral vascular bed), the researchers then randomized the patient either to distal protection (n = 312) or conventional treatment (n = 314).
In the distal protection group, filter placement was attempted in 304 patients (97%) and was successful in 254 patients (81%).
But filter protection afforded no benefit at either 30 days, 6 months, or 15 months later, the researchers said.
Nine cases of definite stent thrombosis occurred in the protection group and one in the control group (2.9% vs 0.3%, p = 0.01).
The rate of target lesion revascularization was also significantly increased in the distal protection group (12.5% vs 7%, p = 0.05), as was the rate of target vessel revascularization (15.4% vs 8.3%, p < 0.01).
The two groups had similar rates of myocardial infarction and mortality.
Dr. Kaltoft’s team suggests that vessel spasm in response to filter placement could lead “to an underestimation of the vessel diameter and to undersizing of the implanted stent, a known predictor of early stent thrombosis.” Other possibilities include damage to the vessel wall at the site of filter deployment or stent apposition during filter retrieval.
Similarly, damage to the vessel wall from pre-dilation or during placement of the filter could increase restenosis rates and the need for repeat revascularization.
Whatever the cause, the authors conclude, “Routine use of a filter wire in its present form cannot be advocated and probably should be avoided with primary PCI for ST-elevation myocardial infarction.”
J Am Coll Cardiol 2010;55:867-871.