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What Would Be the Ideal Drug-eluting Stent for Managing Patients with Long Lesions?
Interventional Cardiology Review, 2009;4(1):44-47
AbstractDrug-eluting stents (DES) substantially reduce the risk of restenosis, particularly in complex coronary disease. Their use is now standard in demanding anatomy, including in long lesions, which represent an increasing proportion of percutaneous coronary intervention (PCI) cases. However, long lesions pose a number of procedural and clinical challenges for DES, specifically stent deliverability, stent overlap and an increased risk of restenosis, peri-procedural myocardial infarction, geographical miss and stent thrombosis. The ideal DES for long lesions would incorporate a number of specific design characteristics to meet these challenges, including low late loss to minimise restenosis risk, thin struts to enhance deliverability and minimise risk of peri-procedural infarction and the availability of long lengths to minimise overlap and avoid geographical miss. It is clear from a knowledge of their properties, and from available data on DES performance in long lesions, that some currently available DES have superior design characteristics and clinical outcomes in the setting of diffuse disease. An awareness of these issues is essential for the practising interventional cardiologist in treating long lesions in routine clinical practice.
Percutaneous coronary intervention, angioplasty, drug-eluting stents, long lesions, restenosis, stent deliverability
Percutaneous coronary intervention, angioplasty, drug-eluting stents, long lesions, restenosis, stent deliverability
Disclosure Rhidian J Shelton has no conflicts of interest to declare. Daniel J Blackman has received speakers honoraria from Boston Scientific, is a member of the advisory boards of Abbott Vascular, Boston Scientific, Cordis (Johnson & Johnson) and Medtronic and has received travel and conference support from Boston Scientific, Cordis (Johnson & Johnson) and Medtronic.
Received: July 24, 2009 | Accepted September 07, 2009 | Citation Interventional Cardiology Review, 2009;4(1):44-47
Correspondence: Daniel J Blackman, Department of Cardiology, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK. E: firstname.lastname@example.org
The introduction of coronary stents in the late 1980s improved outcome over balloon angioplasty via a reduction in acute vessel closure, prevention of vessel recoil, increase in acute gain and a lower rate of clinical restenosis.1,2 However, in-stent restenosis (ISR), caused by smooth-muscle cell proliferation and migration, leading to neointimal hyperplasia, remains the Achilles’ heel of bare-metal stents (BMS). The development of drug-eluting stents (DES), which release antiproliferative drugs into the vessel wall to inhibit neointimal hyperplasia, has revolutionised percutaneous coronary intervention (PCI), dramatically reducing the incidence of ISR and target lesion revascularisation (TLR)3 and permitting the treatment of more complex and extensive coronary artery disease, including diffuse or long lesions.
Long lesions account for approximately 20% of contemporary PCI cases, and present specific challenges for drug-eluting stenting. In this article we describe the difficulties encountered in the treatment of long lesions using DES. We discuss how the characteristics and design of DES could be adapted to overcome these challenges and to deliver an optimal outcome. Finally, we relate these observations to contemporary DES, and discuss the evidence for the performance of the different commercially available DES in the setting of long lesions. For the purposes of this article we will focus on those DES with pivotal phase III randomised controlled trial data at the time of writing, namely the CYPHER sirolimus-eluting stent (SES) (Cordis, Johnson & Johnson, Miami Lakes, FL, US), the TAXUS paclitaxel-eluting stent (PES) (Boston Scientific, Natick, MA, US), the Endeavor Sprint zotarolimus-eluting stent (ZES) (Medtronic, Santa Rosa, CA, US), the Xience V (Abbott Vascular, IL, US)/Promus (Boston Scientific) everolimus-eluting stent (EES) and the Biomatrix biolimus-eluting stent (BES) (Biosensors Interventional, Singapore), although emerging technologies will also be discussed.
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