Original Article
Drug-eluting stent thrombosis in the treatment of chronic total coronary occlusions: Incidence, presentation and related factors. Data from the CIBELES trial
Trombose do stent fármaco ativo no tratamento da oclusões totais coronárias: incidência, apresentação e fatores relacionados. Os dados do ensaio Cibeles
Eduardo Arroyo-Úcara, Raul Morenoa,
, Eulogio Garcíab, Rui Telesc, Jose-Ramon Rumorosod, Henrique Cyrne Carvalhoe, Francisco Javier Goicoleaf, José Moreug, Josefa Maurih, Manel Sabatéi, Vicente Mainarj, Lino Patriciok, Mariano Valdésl, Felipe Fernández-Vázquezm, Angel Sánchez-Recaldea, Guillermo Galeotea, Santiago Jimenez-Valeroa, Manuel Almeidac, Esteban López de Saa, Luis Calvoa..., Ignacio Plazaa, Jose-Luis Lopez-Sendóna, Jose-Luis R. Martínn, for the CIBELES investigators Ver más
Autor para correspondência
a Hospital Universitario La Paz, Madrid, Spain
b Hospital Clinico, Madrid, Spain
c Hospital de Santa Cruz, Lisbon, Portugal
d Hospital de Galdakao, Bilbao, Spain
e Hospital de Santo Antonio, Porto, Portugal
f Hospital Puerta de Hierro, Majadahonda, Spain
g Hospital Virgen de la Salud, Toledo, Spain
h Hospital German Trias I Pujol, Badalona, Spain
i Hospital Santa Creu I Sant Pau, Barcelona, Spain
j Hospital General, Alicante, Spain
k Hospital de Santa Marta, Lisboa, Portugal
l Hospital Virgen de la Arrixaca, Murcia, Spain
m Complejo Hospitalario, León, Spain
n Research Manager, School of Biomedical and Health Sciences, Universidad Europea de Madrid, Spain
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"apellidos" => "Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">n</span>" "identificador" => "aff0070" ] ] ] 23 => array:1 [ "colaborador" => "for the CIBELES investigators" ] ] "afiliaciones" => array:14 [ 0 => array:3 [ "entidad" => "Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Clinico, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital de Santa Cruz, Lisbon, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital de Galdakao, Bilbao, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Hospital de Santo Antonio, Porto, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Hospital Puerta de Hierro, Majadahonda, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Hospital Virgen de la Salud, Toledo, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Hospital German Trias I Pujol, Badalona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Hospital Santa Creu I Sant Pau, Barcelona, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Hospital General, Alicante, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Hospital de Santa Marta, Lisboa, Portugal" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Hospital Virgen de la Arrixaca, Murcia, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Complejo Hospitalario, León, Spain" "etiqueta" => "m" "identificador" => "aff0065" ] 13 => array:3 [ "entidad" => "Research Manager, School of Biomedical and Health Sciences, Universidad Europea de Madrid, Spain" "etiqueta" => "n" "identificador" => "aff0070" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Trombose do <span class="elsevierStyleItalic">stent</span> fármaco ativo no tratamento da oclusões totais coronárias: incidência, apresentação e fatores relacionados. Os dados do ensaio Cibeles" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1262 "Ancho" => 1573 "Tamanyo" => 86505 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Incidence of definite and probable stent thrombosis at 12-month follow-up (overall rate 1.4%). EES: everolimus-eluting stent; SES: sirolimus-eluting stent; ST: stent thrombosis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0035" class="elsevierStylePara elsevierViewall">Chronic total coronary occlusions (CTO) constitute one of the most complex and challenging therapeutic scenarios for an interventional cardiologist, due not only to the technical complexity of the lesion and the need for specific operator skills, but also to the many complications that can occur during and after the procedure.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1–4</span></a> Stent thrombosis (ST) represents the most important clinical complication due to the high rate of death and/or myocardial infarction.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">5</span></a> Its pathophysiology includes various factors related to the device itself, the procedure and the patient.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">It has been traditionally considered that one the factors associated with increased risk of ST is, as suggested by some studies,<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">7,8</span></a> the implantation of a drug-eluting stent (DES) in the context of a CTO. The aim of this study is to assess the incidence, clinical significance and timing of DES thrombosis in the treatment of CTO, given the lack of clear knowledge concerning the safety of these devices in this context. For this purpose, data on ST from the CIBELES trial<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a> were studied.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients</span><p id="par0045" class="elsevierStylePara elsevierViewall">The CIBELES clinical trial (ClinicalTrials.gov number <a href="ctgov:NCT00793221">NCT00793221</a>) included 207 patients with CTO of more than two weeks duration, after successful balloon angioplasty. These patients were randomized to receive an everolimus-eluting stent (EES) (Xience V, Abbott Vascular) or a sirolimus-eluting stent (SES) (Cypher, Cordis). The primary outcome was in-stent late loss. Thirteen centers in Spain and Portugal were involved in this trial, which was sponsored by the Spanish Society of Cardiology. Abbott Vascular supported the study by an unconditional grant.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The antithrombotic therapy, approach (radial or femoral) and material used during the procedure were chosen according to operator preferences or the established protocols of each center. Angiographic follow-up was performed at nine months after revascularization. In the event of significant restenosis, repeat revascularization was performed, if clinically indicated (angina, silent ischemia or presence of myocardial viability) and technically feasible. Quantitative coronary analysis was performed at an independent laboratory using MEDIS software (Leiden, The Netherlands). The study was monitored by Chiltern International, and featured an independent clinical events committee. The clinical follow-up was performed over a period of 12 months after revascularization.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This substudy assesses the incidence, timing, clinical presentation and independent predictors of ST in patients included in the CIBELES trial.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Definitions</span><p id="par0060" class="elsevierStylePara elsevierViewall">The definition of ST used was that of the Academic Research Consortium,<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">10</span></a> as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">(1)</span><p id="par0065" class="elsevierStylePara elsevierViewall">definite thrombosis: documented angiographically or by autopsy;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">(2)</span><p id="par0070" class="elsevierStylePara elsevierViewall">probable thrombosis: an acute coronary syndrome in the territory of the treated artery, or either sudden cardiac or unexplained death in the 30 days after stent implantation;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(3)</span><p id="par0075" class="elsevierStylePara elsevierViewall">possible thrombosis: sudden cardiac or unexplained death beyond 30 days after stent implantation.</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">In view of these criteria, of special interest for the study were the rates of definite or probable thrombosis. From a chronological point of view, thrombosis was considered as:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">(1)</span><p id="par0085" class="elsevierStylePara elsevierViewall">acute: within 24 hours after stent implantation;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">(2)</span><p id="par0090" class="elsevierStylePara elsevierViewall">sub-acute: between the first 24 hours and the first 30 days after stent implantation;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">(3)</span><p id="par0095" class="elsevierStylePara elsevierViewall">late: beyond the first 30 days after stent implantation.</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0100" class="elsevierStylePara elsevierViewall">The collected data were analyzed using SPSS version 12.0 for Windows (SPSS Inc., Chicago, IL, USA). Qualitative variables were expressed as percentages, and quantitative variables as mean ± standard deviation. The chi-square test and Fisher's exact test were used to compare qualitative variables. Multivariate analysis was performed using logistic regression analysis. Comparison between quantitative variables was performed using the Student's t test. A value of p<0.05 was considered statistically significant.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Incidence and clinical presentation of stent thrombosis</span><p id="par0105" class="elsevierStylePara elsevierViewall">The clinical and angiographic characteristics of the study population are summarized in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>. During follow-up, ST was diagnosed in three patients, two definite (1 and 117 days after the procedure) and one probable (nine days after the procedure). The characteristics of these patients are summarized in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The first patient was randomized to the SES group and received three stents. However, a paclitaxel-eluting stent was also implanted distally to the treated lesion. Within 24 hours of the procedure the patient presented acute ST of the paclitaxel device. Although there was no evidence of thrombosis of the SES, this event was classified as definite ST as the design of the analysis was by intention to treat.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The second patient experienced a non-ST-elevation acute coronary syndrome nine days after the initial intervention. This event was initially treated conservatively. At the scheduled angiographic follow-up, coronary angiography demonstrated total occlusion of the target vessel. ST was considered the most likely cause of the event.</p><p id="par0120" class="elsevierStylePara elsevierViewall">A third patient had a definite ST, 117 days after treatment. This patient was admitted with a non-ST-elevation acute coronary syndrome; angiography showed a thrombotic occlusion of the treated target vessel and PCI was subsequently repeated.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The overall rate of definite or probable thrombosis was therefore 1.4% (0.9% early, 0.5% late). In no case did ST lead to death or Q-wave myocardial infarction. The clinical presentation was non-Q-wave myocardial infarction in two cases and unstable angina in one. There were also no documented cases of probable or definite ST in patients assigned to the EES group.</p><p id="par0130" class="elsevierStylePara elsevierViewall">A fourth patient had sudden death of unknown cause eight months after the coronary intervention. ST was considered in this case as possible. Thus, the overall incidence of ST (definite, probable or possible) was 1.8%.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Factors related to stent thrombosis</span><p id="par0135" class="elsevierStylePara elsevierViewall">The univariate analysis (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) revealed that patients with a higher incidence of ST were those who had single-vessel disease (3.3% vs. 0.0%, p=0.049), in whom the lesion was in the anterior descending artery (3.5% vs. 0.0%, p=0.037), and who showed a lower minimum luminal diameter (1.3±0.6 mm vs. 2.6±0.5 mm, p<0.001) immediately after the procedure. Moreover, the ST rate was 3.0% in the SES group compared to 0.0% in the EES group (p=0.074) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Multivariate analysis showed that the only independent predictor of ST in this context was minimal lumen diameter immediately after the procedure (p=0.012).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">ST is an uncommon event, with a variable clinical presentation but generally unfavorable course, resulting in high rates of myocardial infarction (50–70%) or death (20–40%). The data in the literature on its incidence are inconsistent, but it is estimated at between 0.5% and 2.5%. These figures are slightly lower and with earlier clinical presentation for bare-metal stents (BMS).<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">9</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The essential pathophysiology is closely related to various parameters and chronological stages: early events often depend on variables associated with the procedure itself, including the presence of residual thrombus, dissection in the proximity of the target lesion, stasis, stent under-expansion, stent length, or a combination of the above. Late events are most frequently associated with delayed scarring or incomplete and/or inadequate neointimal covering. Additionally, underlying vascular inflammation and the length of the implanted devices have also been shown to be important, with patients who had received longer stents or experienced an allergic reaction to the polymer most often suffering ST.<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">11–13</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Traditionally, percutaneous revascularization of a CTO is considered to be at high risk for ST. This is due to the complexity of the procedure and the intricate histopathology of these lesions, which contain varying amounts of collagen, lipid, calcifications and intraluminal microchannels. All this leads to increased vulnerability and susceptibility to vascular damage.<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">14,15</span></a> Numerous clinical studies have demonstrated the superiority of DES (mainly SES) compared with BMS in the treatment of CTO,<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">16–21</span></a> with a lower restenosis rate and fewer major adverse cardiac events. There are no data in the literature that conclusively demonstrate increased rates of ST in this context. However, ST is slightly more frequent in patients treated with first-generation DES.</p><p id="par0155" class="elsevierStylePara elsevierViewall">The new generations of DES have been developed to improve safety and biocompatibility, optimizing the three main components: the platform, the polymer and the drug. They have been shown to be more effective than the first generation, mainly due to a reduction in the rate of medium-term target vessel revascularization. They have also shown a better safety profile, with lower rates of ST. These findings have been supported by the results of numerous clinical trials published in recent years (SPIRIT II,<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">22</span></a> SPIRIT III,<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">23</span></a> SPIRIT IV,<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">24</span></a> COMPARE I<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">25</span></a>), which compared the two generations of DES.</p><p id="par0160" class="elsevierStylePara elsevierViewall">So the results of the CIBELES trial, which demonstrates the non-inferiority of EES versus SES, should not surprise us. They corroborate the previously published data and establish the safety of EES in the context of CTO. Although it is not possible to draw definite conclusions concerning differences in ST between the two treatment groups, there were no cases of definite or probable thrombosis in the EES arm. Other second-generation stents, such as zotarolimus-eluting stents, have been proven to be at least as effective as SES in the treatment of CTO, offering similar results in terms of numbers of ST.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">26</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">As noted above, ST usually presents as an acute event with a variable spectrum, but usually with high rates of morbidity and mortality. However, in our study the clinical course was relatively benign, presenting in all cases as an episode of unstable angina or a nonfatal non-ST-elevation myocardial infarction. The particular angiographic scenario probably contributed significantly to this clinical course, as pre-existing collateral circulation may have played a protective role in the event of an ischemic event caused by ST.</p><p id="par0170" class="elsevierStylePara elsevierViewall">The data obtained suggest that the only independent predictor of ST is minimal luminal diameter immediately after the procedure. This suggests that stents implanted in small vessels or malpositioned or under-expanded (due to, for example, the existence of underlying calcium) are at higher risk of thrombosis. Recently published data emphasize the low use of non-compliant balloons in the treatment of CTO. In the CIBELES trial, post-dilatation was only performed in 25% of patients, a figure that is surprising given the expected proportion of malpositioning or under-expansion of the implanted stents according to the type and length of the treated lesions. Invasive imaging techniques such as IVUS guided the procedure and its outcome in only 6% of cases.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">27</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">It is known that the same precipitating factors are predictors of ST after revascularization with DES in other coronary lesions.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">28,29</span></a> Analyzing the timing of the event rate, there is no evidence of a clear grouping, with one acute, one subacute, and one late ST in our study. The two early events were presumably related to the procedure itself and associated local complications. Stenting often leads to areas of dissection along the artery, and together with the presence of organized thrombotic material, areas of calcification and suboptimal end TIMI flow, would provide the pathophysiological basis for increased incidence of ST. However, and despite the complexity of the procedure, the frequency of acute and subacute ST is very low, representing only 0.97% of all our cases.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Furthermore, thrombosis associated with DES occurs later than with BMS.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">28</span></a> The main cause of this phenomenon is delayed endothelialization of the device, caused by the antiproliferative action of the drug, as indicated by various angioscopy, optical coherence tomography and autopsy studies, although no definite conclusions can be drawn.<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">30,31</span></a> We found only one case of late ST, but the follow-up in our study was only 12 months after revascularization. Hence, possible very late thrombosis events were not recorded.</p><p id="par0185" class="elsevierStylePara elsevierViewall">In light of the above, we consider that this substudy of the CIBELES trial shows that ST in the context of CTO treated with DES is an uncommon phenomenon, similar to that of other coronary lesions. The previously known predisposing factors account for the majority of the risk, although the importance of certain local factors, such as the frequent presence of underlying calcium or areas of arterial dissection, should be borne in mind. Our data are similar to those published by other groups, in which the efficacy of EES<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">32</span></a> and other second-generation stents<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">33,34</span></a> was assessed, suggesting the existence of a class effect.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Moreover, second-generation DES have tended to diminish ST and are probably better in this regard than the first generation. The clinical presentation is in this context milder than in other circumstances, as the abundant collateral circulation acts as insurance and protects possible at-risk myocardial territory. Therefore, and given the available scientific evidence, we believe that DES stenting in CTO – and even more with second-generation stents – does not lead to added risk of ST, and presents a clear benefit in restenosis rates.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> Invasive imaging techniques such as IVUS or optical coherence tomography, and the use of non-compliant balloons after stent implantation, are useful tools to predict and correct malpositioning or under-expansion, thereby alleviating some of the main triggers of thrombosis.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Study limitations</span><p id="par0195" class="elsevierStylePara elsevierViewall">Our study has some limitations. First, the CIBELES trial was designed to compare stent restenosis with EES and SES, and not to study ST. However, it is not really feasible to perform a specific clinical trial to assess ST in the context of CTO. Secondly, CTO were defined as those with estimated occlusion time >2 weeks (and not >3 months as recommended in recent consensus documents). The data are thus comparable to those of other trials of DES in CTO, such as PRISON II.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> In any case, in our study the estimated duration of occlusion was not related to the rate of ST. Thirdly, since the choice of antiplatelet therapy was at the discretion of the operator, there was no uniformity concerning the dose and type of drug administered. Finally, the clinical monitoring of patients was conducted over a 12-month period, so events after this period were not recorded. Consequently, despite its low incidence, possible very late ST is not included in this study.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall">The rate of thrombosis of DES in patients with CTO is low (1.4%), especially in those treated with EES compared to SES. In this context, the only independent predictor is minimal luminal diameter after the procedure. The clinical presentation in all cases was relatively benign (unstable angina or nonfatal non-ST-elevation myocardial infarction). The use of DES in the treatment of CTO is a safe option and should not be considered to increase risk of thrombosis.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Ethical disclosures</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Protection of human and animal subjects</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Confidentiality of data</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Right to privacy and informed consent</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">This study was supported by the Spanish Society of Cardiology, with an unrestricted grant by Abbott Vascular.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres458081" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec481083" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres458082" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec481082" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Definitions" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Incidence and clinical presentation of stent thrombosis" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Factors related to stent thrombosis" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Study limitations" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 10 => array:3 [ "identificador" => "sec0060" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-07-15" "fechaAceptado" => "2014-08-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec481083" "palabras" => array:5 [ 0 => "<span class="elsevierStyleItalic">Stent</span>" 1 => "Thrombosis" 2 => "<span class="elsevierStyleItalic">Everolimus</span>" 3 => "<span class="elsevierStyleItalic">Sirolimus</span>" 4 => "Chronic total coronary occlusion" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec481082" "palabras" => array:5 [ 0 => "<span class="elsevierStyleItalic">Stent</span>" 1 => "Trombose" 2 => "Everolimus" 3 => "Sirolimus" 4 => "Oclusão coronária crónica total" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to analyze the incidence of drug-eluting stent thrombosis (sirolimus or everolimus) in patients with chronic total coronary occlusions (CTO) and to determine its clinical implications and related factors.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Data from the 12-month follow-up of the 207 patients included in the CIBELES trial with CTO were analyzed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Stent thrombosis occurred in three patients, two definite and one probable (overall thrombosis rate: 1.4%). However, there were no cases of death or Q-wave myocardial infarction. In univariate analysis, patients with a higher incidence of stent thrombosis were those in whom the target vessel was the left anterior descending, who had single-vessel disease, were assigned to treatment with sirolimus-eluting stents, and those with smaller minimum luminal diameter immediately after the procedure. In multivariate analysis, the only independent predictor of stent thrombosis was minimal luminal diameter immediately after the procedure.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The rate of drug-eluting stent thrombosis in patients with CTO is relatively low (1.4%). The only independent predictor of stent thrombosis in this context was minimal luminal diameter after the procedure and the clinical presentation was in all cases relatively benign.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdução e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">o objetivo do nosso estudo foi analisar a incidência de trombose de <span class="elsevierStyleItalic">stent</span> com eluição de fármaco (<span class="elsevierStyleItalic">sirolimus</span> ou <span class="elsevierStyleItalic">everolimus</span>) em pacientes com oclusões coronárias crónicas e identificar as suas implicações clínicas e fatores relacionados.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">12 meses de acompanhamento dos 207 pacientes incluídos no ensaio Cibeles com oclusão total coronária crónica.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">a trombose de <span class="elsevierStyleItalic">stent</span> ocorreu em três doentes: duas definitivas e uma provável (taxa global de trombose 1,4%). No entanto, não surgiu nenhum caso de morte ou enfarte do miocárdio com onda Q. Na análise univariada, os doentes com maior incidência de trombose de <span class="elsevierStyleItalic">stent</span> foram aqueles em que o vaso-alvo foi a descendente anterior, os que tinham a doença de um vaso, os que foram considerados para tratamento com <span class="elsevierStyleItalic">stent</span> com <span class="elsevierStyleItalic">sirolimus</span>, e aqueles com diâmetro luminal mínimo menor imediatamente após o procedimento. Na análise multivariada, o único preditor independente de trombose do <span class="elsevierStyleItalic">stent</span> foi o diâmetro luminal mínimo imediatamente após o procedimento.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusões</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">a taxa de trombose de <span class="elsevierStyleItalic">stent</span> farmacológico em pacientes com oclusão coronária crónica foi relativamente baixa (1,4%).</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">O único preditor independente de trombose de <span class="elsevierStyleItalic">stent</span> neste contexto foi o diâmetro luminal mínimo após o procedimento, tendo a apresentação clínica em todos os casos sido relativamente benigna.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0065">List of abbreviations</span>" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:6 [ 0 => array:2 [ "termino" => "CTO" "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">chronic total occlusion</p>" ] 1 => array:2 [ "termino" => "ST" "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">stent thrombosis</p>" ] 2 => array:2 [ "termino" => "EES" "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">everolimus-eluting stent</p>" ] 3 => array:2 [ "termino" => "SES" "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">sirolimus-eluting stent</p>" ] 4 => array:2 [ "termino" => "DES" "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">drug-eluting stent</p>" ] 5 => array:2 [ "termino" => "BMS" "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">bare-metal stent</p>" ] ] ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1262 "Ancho" => 1573 "Tamanyo" => 86505 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Incidence of definite and probable stent thrombosis at 12-month follow-up (overall rate 1.4%). EES: everolimus-eluting stent; SES: sirolimus-eluting stent; ST: stent thrombosis.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">LVEF: left ventricular ejection fraction; MI: myocardial infarction; PAD: peripheral arterial disease; PCI: percutaneous coronary intervention.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No thrombosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Thrombosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67±6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64±10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.493 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Female (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diabetes (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.555 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hypertension (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.553 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hypercholesterolemia (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Smoking (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.256 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PAD (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">LVEF (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53±13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.568 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Creatinine (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8±0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.0±0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.499 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Blood glucose (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93±22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120±50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.499 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Previous PCI (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.265 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Previous surgery (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Previous MI (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab709895.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of the study population.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Thrombosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No thrombosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Number of affected vessels</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1±0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8±0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.080 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Number of stents</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.7±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.0±1.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.254 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Maximum stent diameter (mm)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.8±0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.9±0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.438 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Stent length (mm)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.7±19.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.7±24.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.422 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Reference diameter (mm)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.7±0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.0±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.694 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Minimal luminal diameter (mm)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.3±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.2±0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Post-procedural stenosis (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.8±13.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.4±9.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Post-procedural TIMI flow</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.7±0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.9±0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.288 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Balloon over-dilation</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0±0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3±0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.313 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Multivessel disease (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.049 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Location anterior descending (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.037 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Bifurcation (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Radial approach (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Retrograde access (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Anticoagulant used (%)</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sodium heparin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.438 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bivalirudin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.322 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Enoxaparin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Time of occlusion >3 months (%)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.495 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab709897.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Angiographic characteristics of the study population.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">EES: everolimus-eluting stent; NSTEMI: non-ST-elevation myocardial infarction; SES: sirolimus-eluting stent.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Type \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Stent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Time \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="middle" scope="col" style="border-bottom: 2px solid black">Presentation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="middle">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">Definite \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">SES \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">24 hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">Angina \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="middle">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">Probable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">SES \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">9 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">NSTEMI \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="middle">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">Definite \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">SES \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">117 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">NSTEMI \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="middle">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">Possible \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">EES \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">8 month \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="middle">Sudden death \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab709896.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Characteristics and clinical presentation of patients with stent thrombosis.</p>" ] ] ] 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 10 | 6 | 16 |
| 2024 Outubro | 41 | 34 | 75 |
| 2024 Setembro | 49 | 19 | 68 |
| 2024 Agosto | 43 | 25 | 68 |
| 2024 Julho | 49 | 30 | 79 |
| 2024 Junho | 48 | 19 | 67 |
| 2024 Maio | 47 | 16 | 63 |
| 2024 Abril | 41 | 28 | 69 |
| 2024 Maro | 47 | 23 | 70 |
| 2024 Fevereiro | 36 | 29 | 65 |
| 2024 Janeiro | 33 | 30 | 63 |
| 2023 Dezembro | 25 | 14 | 39 |
| 2023 Novembro | 41 | 21 | 62 |
| 2023 Outubro | 22 | 17 | 39 |
| 2023 Setembro | 22 | 16 | 38 |
| 2023 Agosto | 50 | 14 | 64 |
| 2023 Julho | 35 | 11 | 46 |
| 2023 Junho | 33 | 11 | 44 |
| 2023 Maio | 51 | 17 | 68 |
| 2023 Abril | 43 | 8 | 51 |
| 2023 Maro | 103 | 28 | 131 |
| 2023 Fevereiro | 67 | 15 | 82 |
| 2023 Janeiro | 24 | 11 | 35 |
| 2022 Dezembro | 42 | 19 | 61 |
| 2022 Novembro | 83 | 21 | 104 |
| 2022 Outubro | 30 | 16 | 46 |
| 2022 Setembro | 32 | 23 | 55 |
| 2022 Agosto | 43 | 34 | 77 |
| 2022 Julho | 47 | 33 | 80 |
| 2022 Junho | 32 | 28 | 60 |
| 2022 Maio | 23 | 20 | 43 |
| 2022 Abril | 39 | 21 | 60 |
| 2022 Maro | 31 | 29 | 60 |
| 2022 Fevereiro | 33 | 30 | 63 |
| 2022 Janeiro | 31 | 18 | 49 |
| 2021 Dezembro | 18 | 25 | 43 |
| 2021 Novembro | 44 | 34 | 78 |
| 2021 Outubro | 35 | 29 | 64 |
| 2021 Setembro | 38 | 28 | 66 |
| 2021 Agosto | 35 | 29 | 64 |
| 2021 Julho | 30 | 28 | 58 |
| 2021 Junho | 43 | 29 | 72 |
| 2021 Maio | 28 | 17 | 45 |
| 2021 Abril | 53 | 34 | 87 |
| 2021 Maro | 63 | 24 | 87 |
| 2021 Fevereiro | 72 | 11 | 83 |
| 2021 Janeiro | 40 | 5 | 45 |
| 2020 Dezembro | 29 | 7 | 36 |
| 2020 Novembro | 35 | 10 | 45 |
| 2020 Outubro | 19 | 9 | 28 |
| 2020 Setembro | 40 | 13 | 53 |
| 2020 Agosto | 28 | 5 | 33 |
| 2020 Julho | 51 | 9 | 60 |
| 2020 Junho | 34 | 4 | 38 |
| 2020 Maio | 44 | 2 | 46 |
| 2020 Abril | 34 | 12 | 46 |
| 2020 Maro | 49 | 7 | 56 |
| 2020 Fevereiro | 55 | 15 | 70 |
| 2020 Janeiro | 37 | 5 | 42 |
| 2019 Dezembro | 27 | 6 | 33 |
| 2019 Novembro | 40 | 8 | 48 |
| 2019 Outubro | 37 | 6 | 43 |
| 2019 Setembro | 24 | 8 | 32 |
| 2019 Agosto | 37 | 3 | 40 |
| 2019 Julho | 28 | 9 | 37 |
| 2019 Junho | 40 | 14 | 54 |
| 2019 Maio | 37 | 9 | 46 |
| 2019 Abril | 28 | 15 | 43 |
| 2019 Maro | 96 | 13 | 109 |
| 2019 Fevereiro | 83 | 15 | 98 |
| 2019 Janeiro | 110 | 3 | 113 |
| 2018 Dezembro | 96 | 10 | 106 |
| 2018 Novembro | 207 | 22 | 229 |
| 2018 Outubro | 541 | 12 | 553 |
| 2018 Setembro | 122 | 18 | 140 |
| 2018 Agosto | 89 | 10 | 99 |
| 2018 Julho | 35 | 7 | 42 |
| 2018 Junho | 38 | 10 | 48 |
| 2018 Maio | 46 | 6 | 52 |
| 2018 Abril | 39 | 17 | 56 |
| 2018 Maro | 64 | 7 | 71 |
| 2018 Fevereiro | 36 | 3 | 39 |
| 2018 Janeiro | 37 | 7 | 44 |
| 2017 Dezembro | 70 | 15 | 85 |
| 2017 Novembro | 51 | 11 | 62 |
| 2017 Outubro | 36 | 12 | 48 |
| 2017 Setembro | 46 | 11 | 57 |
| 2017 Agosto | 44 | 13 | 57 |
| 2017 Julho | 22 | 4 | 26 |
| 2017 Junho | 59 | 13 | 72 |
| 2017 Maio | 60 | 14 | 74 |
| 2017 Abril | 41 | 7 | 48 |
| 2017 Maro | 47 | 9 | 56 |
| 2017 Fevereiro | 63 | 13 | 76 |
| 2017 Janeiro | 49 | 3 | 52 |
| 2016 Dezembro | 32 | 6 | 38 |
| 2016 Novembro | 15 | 9 | 24 |
| 2016 Outubro | 42 | 4 | 46 |
| 2016 Setembro | 38 | 6 | 44 |
| 2016 Agosto | 9 | 7 | 16 |
| 2016 Julho | 9 | 3 | 12 |
| 2016 Junho | 22 | 10 | 32 |
| 2016 Maio | 11 | 3 | 14 |
| 2016 Abril | 24 | 5 | 29 |
| 2016 Maro | 66 | 14 | 80 |
| 2016 Fevereiro | 73 | 25 | 98 |
| 2016 Janeiro | 55 | 26 | 81 |
| 2015 Dezembro | 55 | 12 | 67 |
| 2015 Novembro | 63 | 15 | 78 |
| 2015 Outubro | 52 | 20 | 72 |
| 2015 Setembro | 63 | 19 | 82 |
| 2015 Agosto | 52 | 12 | 64 |
| 2015 Julho | 40 | 4 | 44 |
| 2015 Junho | 40 | 6 | 46 |
| 2015 Maio | 66 | 18 | 84 |
| 2015 Abril | 101 | 49 | 150 |
| 2015 Maro | 87 | 89 | 176 |
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