Stents, by Ryan Colombo

Background

Precutaneous coronary intervention, pioneered by Dr. Gruntzig in 1977, is the most frequently performed medical procedure [1]. In the past, this was performed using balloon angioplasty. However, this procedure was subject to detrimental vessel closure due to dissection and restentosis [1]. The stent was developed to maintain lumen integrity.

Bare Metal Stents

One of the major problems with bare metal stents is the occurrence of neointimal hyperplasia following impantation [1]. This leads to restentosis, or a re-narrowing of the blood veseel, and requires revascularization. This has occurred in up to a third of patients treated with bare metal stents [1].

Drug Eluting Stents

Drug eluting stents are characterized by the controlled release of immunosupressive and antiproliferative agents, which act to inhibit the accumulation of smooth muscle cells [1]. These stents are superior to bare metal stents with respect to prevention of restenosis.

Traditionally, stents have been constructed from stainless steel [1]. New generation stents are now being fabricated from cobalt-chrome alloys, which exhibit improved radial strength with thinner struts. Radial strength is being further improved upon via the introduction of platinum-chrome stents [1]. Thinner struts are thought to result in less arterial injury, thus reducing thrombosis and restenosis.

The polymer coating on the stent enables controlled drug release. These coatings must be biocompatible in order to decrease local inflammatory reactions and thrombosis [1]. Polymers that biodegrade are currently undergoing clinical trials [1].

First Generation Drug Eluting Stents

First generation DES's are characterized by the timed release of sirolimus or paclitaxel. These antiproliferative drugs reduce revascularization as a result of neointimal hyperplasia. Similar risks of death and myocardial infraction exist as compared to BMS's [1].

In 2006, the European Society of Cardiology Congress cited stents releasing paclitaxel or sirolimus as slightly increasing the risk of thrombosis [1]. As of 2013, drug eluting stents are implanted in more than 500,000 patients per year [1]. Clinical studies of paclitaxel-eluting stents have ceased, and sirolimus-eluting stents are no longer manufactured.

Too much antiproliferation can retard or inhibit arterial wall healing, which leads to chronic inflammation [1].

Second Generation Drug Eluting Stents and the Future

New generation stents release everolimus and zotarolimus [1]. Clinical trials have demonstrated that everolimus reduces the risk of repeat revascularization, heart attack, and stent thrombosis compared to paclitaxel and sirolimus eluting stents [1]. Compared with paclitaxel, zotarolimus resuces the risk of myocardial infraction [1].

References

[1] Stefanini G., Holmes D. Drug eluting coronary-artery stents. New England Journal of Medicine, 2013, 368:254-65.