Comparison of the Efficacy of Direct Coronary Stenting With Sirolimus-Eluting Stents Versus Stenting With Predilation by Intravascular Ultrasound Imaging (from the DIRECT Trial)

A direct coronary stenting technique using drug-eluting stents may decrease drug-eluting stent efficacy due to possible damage to the surface coating of the stent. The DIRECT is a multicenter, prospective, nonrandomized trial designed to evaluate the direct stenting strategy for the sirolimus-eluting Bx-Velocity stent compared with the historical control (SIRIUS trial, stenting with predilation). Volumetric and cross-sectional intravascular ultrasound analyses at 8-month follow-up were performed in 115 patients (DIRECT n= 64, control n = 51). Patient and lesion characteristics were comparable between groups. The DIRECT group achieved an equivalent uniform expansion index, defined as minimum stent area/maximum stent area × 100, compared with the control group (65.9 ± 11.7 vs 63.1 ± 12.7, p = NS). At 8-month follow-up, vessel, stent, lumen, and neointimal volume index (volume in cubic millimeters/length in millimeters) and percent neointimal volume were similar between the DIRECT and control groups (vessel volume index 13.9 ± 4.40 vs 15.0 ± 3.83; stent volume index 6.83 ± 2.02 vs 6.94 ± 2.04; lumen volume index 6.71 ± 2.04 vs 6.81 ± 2.07; neointimal volume index 0.14 ± 0.24 vs 0.16 ± 0.23; percent neointimal volume 3.73 ± 6.97 vs 3.14 ± 5.32, p = NS for all). In addition, in-stent neointimal hyperplasia distribution was significantly smaller near the distal stent edge (0.22 vs 0.098 mm3/mm, p = 0.01 for an average neointimal volume index within 3 mm from the distal stent edge). In conclusion, direct coronary stenting with the sirolimus-eluting Bx-Velocity stent is equally effective in terms of uniform stent expansion and long-term quantitative intravascular ultrasound results compared with conventional stenting using predilation. This strategy appears to be associated with less neointimal hyperplasia near the distal stent edge.