Coronary stenting: Difference between revisions

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=Introduction=
=Introduction=
In the early years of percutaneous coronary intervention (PCI) the only available method to treat coronary stenoses was balloon angioplasty. However, balloon angioplasty alone, also known as plain old balloon angioplasty (POBA) was hampered by a few important technical limitations. For example, an important early complication of POBA was acute vessel closure,  which could only be treated with emergency coronary artery bypass graft surgery (CABG).(1) Moreover, acute vessel recoil at the site of balloon inflation led to suboptimal early results of POBA, and restenosis rates were frequently reported to be >20%.  The introduction of coronary artery stents, pioneered by Julio Palmaz, Richard Schatz, Cesare Gianturco and Gary Roubin,  led to important advances in PCI.(2) By virtually eliminating acute vessel closure, hospitals were PCIs were performed no longer needed a surgical backup team, and for many years now PCIs are performed in hospitals without cardiothoracic surgery departments. Moreover, restenosis rates were reduced by as much as 50% with the use of bare metal stents (BMS) compared with POBA.(3, 4) However, the introduction of the BMS also introduced the complication of stent thrombosis which occurs in 2-5% of patients depending on lesion and patient characteristics. More recently, at the beginning of the current millennium drug-eluting stents (DES) caused another revolution in PCI. Again, restenosis rates were cut in half compared with BMS and the latest generation of DES with bio-compatible polymers have been shown to reduce stent thrombosis compared with BMS. This section provides an overview about technical specifications, and data on safety and efficacy of different types of coronary artery stents.
In the early years of percutaneous coronary intervention (PCI) the only available method to treat coronary stenoses was balloon angioplasty. However, balloon angioplasty alone, also known as plain old balloon angioplasty (POBA) was hampered by a few important technical limitations. For example, an important early complication of POBA was acute vessel closure,  which could only be treated with emergency coronary artery bypass graft surgery (CABG).<cite>Detre</cite> Moreover, acute vessel recoil at the site of balloon inflation led to suboptimal early results of POBA, and restenosis rates were frequently reported to be >20%.  The introduction of coronary artery stents, pioneered by Julio Palmaz, Richard Schatz, Cesare Gianturco and Gary Roubin,  led to important advances in PCI.<cite>Sigwart</cite> By virtually eliminating acute vessel closure, hospitals were PCIs were performed no longer needed a surgical backup team, and for many years now PCIs are performed in hospitals without cardiothoracic surgery departments. Moreover, restenosis rates were reduced by as much as 50% with the use of bare metal stents (BMS) compared with POBA.<cite>Fischman</cite><cite>Serruys</cite> However, the introduction of the BMS also introduced the complication of stent thrombosis which occurs in 2-5% of patients depending on lesion and patient characteristics. More recently, at the beginning of the current millennium drug-eluting stents (DES) caused another revolution in PCI. Again, restenosis rates were cut in half compared with BMS and the latest generation of DES with bio-compatible polymers have been shown to reduce stent thrombosis compared with BMS. This section provides an overview about technical specifications, and data on safety and efficacy of different types of coronary artery stents.


=Bare Metal Stents=
=Bare Metal Stents=
Bare-metal stents are made of different types of metals, for example stainless steel, nitinol, cobalt-chromium or platinum-chromium. Stents can be either self-expanding, or balloon-expandable, and exert a scaffolding force to prevent acute recoil of the treated coronary artery stenosis. Bare-metal stents were introduced in the 1980s in an effort to prevent acute vessel occlusion and restenosis, two common complications after POBA. An early report on the use of BMS in coronary arteries was cause for optimism, in 19 patients who received stainless-steel BMS in the mid-1980s (before the era of dual antiplatelet therapy, DAPT) two acute stent occlusions occurred, and one patient died (without suspicion for a thrombotic occlusion), and no further restenosis or occlusions were observed up to nine-month follow-up.(2) <br />
Bare-metal stents are made of different types of metals, for example stainless steel, nitinol, cobalt-chromium or platinum-chromium. Stents can be either self-expanding, or balloon-expandable, and exert a scaffolding force to prevent acute recoil of the treated coronary artery stenosis. Bare-metal stents were introduced in the 1980s in an effort to prevent acute vessel occlusion and restenosis, two common complications after POBA. An early report on the use of BMS in coronary arteries was cause for optimism, in 19 patients who received stainless-steel BMS in the mid-1980s (before the era of dual antiplatelet therapy, DAPT) two acute stent occlusions occurred, and one patient died (without suspicion for a thrombotic occlusion), and no further restenosis or occlusions were observed up to nine-month follow-up.<cite>Sigwart</cite> <br />
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However, a study published in 1991 in the New England Journal of Medicine reported sobering outcomes in a series of 105 patients undergoing BMS implantation.(5) Complete occlusion of the coronary artery stent was observed in 24% of patients at follow-up coronary  angiography after one month. Out of the 27 occlusions, 21 occurred within the first 14 days after stent implantation. Moreover, restenosis (defined as >50% diameter stenosis at follow-up) was observed in 14% of patients with patent stents. An excerpt from the accompanying editorial reflects the disappointment that ensued “I believe that the introduction of most these new devices will be of passing interest only. The development of mechanical interventions (such as stents) that attempt to overcome the response to injury caused by intravascular therapeutic interventions (such as balloon angioplasty) is probably futile.”(6) <br />
However, a study published in 1991 in the New England Journal of Medicine reported sobering outcomes in a series of 105 patients undergoing BMS implantation.<cite>Serruys2</cite> Complete occlusion of the coronary artery stent was observed in 24% of patients at follow-up coronary  angiography after one month. Out of the 27 occlusions, 21 occurred within the first 14 days after stent implantation. Moreover, restenosis (defined as >50% diameter stenosis at follow-up) was observed in 14% of patients with patent stents. An excerpt from the accompanying editorial reflects the disappointment that ensued “I believe that the introduction of most these new devices will be of passing interest only. The development of mechanical interventions (such as stents) that attempt to overcome the response to injury caused by intravascular therapeutic interventions (such as balloon angioplasty) is probably futile.”(6) <br />
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During the 1990s, important developments in pharmacology, stent implantation technique, and BMS technology resulted in markedly improved outcomes after PCI with BMS compared to the aforementioned early experiences. <br />
During the 1990s, important developments in pharmacology, stent implantation technique, and BMS technology resulted in markedly improved outcomes after PCI with BMS compared to the aforementioned early experiences. <br />
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== References ==
== References ==
<biblio>
<biblio>
#Detre pmid=2527641
#Sigwart pmid=2950322
#Fischman pmid=8041414
#Serruys pmid=8041413
#Serruys2 pmid=1984159
#Wieling pmid=15310717
#Wieling pmid=15310717
#Wieling pmid=15310717
#Wieling pmid=15310717
#Wieling pmid=15310717
#Wieling pmid=15310717
#Wieling pmid=15310717
#Wieling pmid=15310717
#Wieling pmid=15310717
#Wieling pmid=15310717
#Wieling pmid=15310717
#Wieling pmid=15310717
5. Serruys PW, Strauss BH, Beatt KJ, Bertrand ME, Puel J, Rickards AF, et al. Angiographic follow-up after placement of a self-expanding coronary-artery stent. The New England journal of medicine. 1991;324(1):13-7.
6. Block PC. Coronary-artery stents and other endoluminal devices. The New England journal of medicine. 1991;324(1):52-3.
7. Colombo A, Hall P, Nakamura S, Almagor Y, Maiello L, Martini G, et al. Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. Circulation. 1995;91(6):1676-88.
8. Claessen BE, Henriques JP, Jaffer FA, Mehran R, Piek JJ, Dangas GD. Stent thrombosis: a clinical perspective. JACC Cardiovascular interventions. 2014;7(10):1081-92.
9. Kastrati A, Mehilli J, Dirschinger J, Dotzer F, Schuhlen H, Neumann FJ, et al. Intracoronary stenting and angiographic results: strut thickness effect on restenosis outcome (ISAR-STEREO) trial. Circulation. 2001;103(23):2816-21.
10. Pache J, Kastrati A, Mehilli J, Schuhlen H, Dotzer F, Hausleiter J, et al. Intracoronary stenting and angiographic results: strut thickness effect on restenosis outcome (ISAR-STEREO-2) trial. Journal of the American College of Cardiology. 2003;41(8):1283-8.
11. Claessen BE, Henriques JP, Dangas GD. Clinical studies with sirolimus, zotarolimus, everolimus, and biolimus A9 drug-eluting stent systems. Current pharmaceutical design. 2010;16(36):4012-24.
12. Morice MC, Serruys PW, Sousa JE, Fajadet J, Ban Hayashi E, Perin M, et al. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. The New England journal of medicine. 2002;346(23):1773-80.
13. Stone GW, Ellis SG, Colombo A, Grube E, Popma JJ, Uchida T, et al. Long-term safety and efficacy of paclitaxel-eluting stents final 5-year analysis from the TAXUS Clinical Trial Program. JACC Cardiovascular interventions. 2011;4(5):530-42.
14. Stone GW, Moses JW, Ellis SG, Schofer J, Dawkins KD, Morice MC, et al. Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. The New England journal of medicine. 2007;356(10):998-1008.
15. Navarese EP, Tandjung K, Claessen B, Andreotti F, Kowalewski M, Kandzari DE, et al. Safety and efficacy outcomes of first and second generation durable polymer drug eluting stents and biodegradable polymer biolimus eluting stents in clinical practice: comprehensive network meta-analysis. Bmj. 2013;347:f6530.
16. Urban P, Meredith IT, Abizaid A, Pocock SJ, Carrie D, Naber C, et al. Polymer-free Drug-Coated Coronary Stents in Patients at High Bleeding Risk. The New England journal of medicine. 2015;373(21):2038-47.
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</biblio>