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Drug-eluting intracoronary stents: General principles

Authors
J Dawn Abbott, MD, FACC
Donald Cutlip, MD
Section Editor
Stephan Windecker, MD
Deputy Editor
Gordon M Saperia, MD, FACC

INTRODUCTION

Drug-eluting stents (DES) reduce the rate of restenosis and, accordingly, target lesion revascularization compared to bare metal stents (BMS). DES consist of a standard metallic stent, a polymer coating, and an anti-restenotic drug (eg, sirolimus or a derivative of sirolimus or paclitaxel) that is mixed within the polymer and is released over a period of weeks to months after implantation to reduce the local proliferative healing response. DES types currently approved for use in the United States are shown in a table (table 1). The sirolimus-eluting stent is no longer manufactured and several stents have been redesigned since their initial approval.

This topic will present the mechanisms of benefit of DES and discuss a few procedural and safety issues. The discussions of the comparison of DES to BMS and of one DES to another are found elsewhere. (See "Clinical use of intracoronary bare metal stents" and "Comparison of drug-eluting intracoronary stents".)

MECHANISMS OF BENEFIT

Late lumen loss and restenosis after nonstent interventions are caused by a combination of acute recoil, negative remodeling (arterial contraction) of the treated segment, and local neointimal hyperplasia. In contrast, late lumen loss after stenting is due solely to in-stent neointimal hyperplasia, as the main benefit of stents is to prevent recoil and negative remodeling. Stents retain a larger acute lumen diameter (than balloon angioplasty) that offsets the reduction in lumen diameter from neointimal hyperplasia. (See "Intracoronary stent restenosis", section on 'Pathogenesis'.)

The restenosis benefit of drug-eluting stents (DES) compared to bare metal stent (BMS) results from inhibition of in-stent neointimal hyperplasia [1], which is reflected as a lesser degree of late in-stent lumen loss at six to nine months (0.1 to 0.4 versus 0.9 to 1.0 mm with BMS) [2-5]. Neointimal suppression is sustained at two years [6].

Biologic characteristics of the four available antirestenotic drugs that have been used in DES include [7]:

         

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Literature review current through: Nov 2016. | This topic last updated: Wed Mar 02 00:00:00 GMT+00:00 2016.
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