Coronary stenting: A matter of revascularization

Abstract

In the last few decades, the recommended treatment for coronary artery disease has been dramatically improved by percutaneous coronary intervention (PCI) and the use of balloon catheters, bare metal stents (BMSs), and drug-eluting stents (DESs). Catheter balloons were burdened by acute vessel occlusion or target-lesion re-stenosis. BMSs greatly reduced those problems holding up the vessel structure, but showed high rates of in-stent re-stenosis, which is characterized by neo-intimal hyperplasia and vessel remodeling leading to a re-narrowing of the vessel diameter. This challenge was overtaken by first-generation DESs, which reduced re-stenosis rates to nearly 5%, but demonstrated delayed arterial healing and risk for late in-stent thrombosis, with inflammatory cells playing a pivotal role. Finally, new-generation DESs, characterized by innovations in design, metal composition, surface polymers, and anti-proliferative drugs, finally reduced the risk for stent thrombosis and greatly improved revascularization outcomes. New advances include bioresorbable stents potentially changing the future of revascularization techniques as the concept bases upon the degradation of the stent scaffold to inert particles after its function expired, thus theoretically eliminating risks linked with both stent thrombosis and re-stenosis. Talking about DESs also dictates to consider dual antiplatelet therapy (DAPT), which is a fundamental moment in view of the good outcome duration, but also deals with bleeding complications. The better management of patients undergoing PCI should include the use of DESs and a DAPT finely tailored in consideration of the potentially developing bleeding risk in accordance with the indications from last updated guidelines.

Keywords: Drug-eluting stent; Bare metal stent; In-stent re-stenosis; Stent thrombosis; Coronary artery disease

Core tip: Percutaneous coronary intervention (PCI) has made progress in leaps and bounds in the last 20 years. Complications occurring with catheter balloons and bare metal stents have been overwhelmed by drug-eluting stents (DESs), especially the new-generation ones. They are characterized by innovations in design, metal composition, surface polymers, and anti-proliferative drugs, thus reducing the risk for stent thrombosis and greatly improving revascularization outcomes. DESs also need dual antiplatelet therapy (DAPT), but the latter implies bleeding complications, too. Patients undergoing PCI should be implanted with DESs and DAPT should be tailored on each patient considering the bleeding risk.