ORIGINAL PAPER Outcomes of Second Revascularization Procedures after Stent Implantation Richard P. Konstance & Eric L. Eisenstein & Kevin J. Anstrom & Linda K. Shaw & Robert M. Califf & Robert A. Harrington & David B. Matchar & Kevin A. Schulman & David F. Kong Received: 24 September 2007 / Accepted: 14 November 2007 / Published online: 17 January 2008 # Springer Science + Business Media, LLC 2007 Abstract Drug-eluting stents (DES) reduce subsequent revascularization procedures. Although randomized trials have compared DES to brachytherapy and balloon angio- plasty (PTCA) for in-stent restenosis, few long-term comparisons have been made to bare metal stents (BMS) or bypass surgery (CABG), particularly following second procedures. We sought to assess the association between revascularization modality and long-term clinical outcomes of patients receiving a second procedure for coronary artery disease. Between January 2000 and July 2005, 4,666 consecutive patients underwent initial coronary stent im- plantation (DES or BMS). From this population we identified 569 patients undergoing a second target vessel revascularization (DES, BMS, PTCA or CABG). Outcomes were assessed at 6, 12, and 24 months after the second procedure, with follow-up through September 2006. Ad- justed cumulative incidence rates were calculated using inverse probability weighted estimators. We found that at 24 months, there were no significant differences in death or myocardial infarction for PTCA, BMS, DES, and CABG (17.7%, 14.9%, 7.5%, and 10.2%, p =0.26[3df]). DES patients had lower rates of death or myocardial infarction or third target vessel procedures than patients receiving PTCA (14.6% vs. 30.0%, p =0.01) and BMS (14.6% vs. 42.2%, p <0.01), but rates similar to CABG patients (14.6% vs. 14.6%, p =0.99). For patients undergoing a second revascularization procedure, PTCA, BMS, DES, and CABG are associated with a similar risk of death or non- fatal myocardial infarction. DES and CABG are associated with lower rates of third revascularization procedures compared to PTCA and BMS. Further studies are needed to determine the optimum application for CABG vs. DES as a second or third revascularization procedure. Keywords Stent . Restenosis . Coronary bypass surgery . Survival . Myocardial infarction . Revascularization Abbreviations BMS Bare metal stent CABG Coronary artery bypass grafting DES Drug-eluting stent DF Degrees of freedom MI Myocardial infarction PTCA Balloon angioplasty TVR Target vessel revascularization TVR3 Third target vessel revascularization J Med Syst (2008) 32:177–186 DOI 10.1007/s10916-007-9120-x R. P. Konstance : E. L. Eisenstein : R. M. Califf : R. A. Harrington : D. B. Matchar : K. A. Schulman : D. F. Kong Department of Medicine, Duke University Medical Center, Durham, NC, USA K. J. Anstrom Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA R. P. Konstance : E. L. Eisenstein (*) : K. J. Anstrom : L. K. Shaw : R. M. Califf : R. A. Harrington : K. A. Schulman : D. F. Kong Duke Clinical Research Institute, DUMC Box 3865, Durham, NC 27710, USA e-mail: eric.eisenstein@duke.edu R. P. Konstance : E. L. Eisenstein : K. J. Anstrom : L. K. Shaw : R. M. Califf : R. A. Harrington : D. B. Matchar : K. A. Schulman : D. F. Kong Duke Translational Medicine Institute, Durham, NC, USA D. B. Matchar Duke Center for Clinical Health Policy Research, Durham, NC, USA