General principles of the use of intracoronary stents
- Thomas Levin, MD
Thomas Levin, MD
- Illinois Heart and Vascular
- Chicago, Illinois
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
Percutaneous coronary intervention (PCI) refers to both non-stent procedures on one or more coronary arteries such as balloon angioplasty or atherectomy as well as stent interventions. The introduction of balloon angioplasty, formally termed percutaneous transluminal coronary angioplasty (PTCA), in the 1970s provided a nonsurgical revascularization alternative to coronary artery bypass graft surgery (CABG). However, acute arterial recoil and coronary dissection were early and potentially fatal complications of the procedure and angiographic restenosis occurred in approximately 40 percent of patients at six months, 50 to 75 percent of whom had recurrent ischemic symptoms. Accordingly, 20 to 30 percent of patients required repeat revascularization of the initially treated lesion within the first year after balloon angioplasty. Recurrent ischemic symptoms after one year were most often due to a new or progressive lesion; the initially treated lesion remained stable or actually regressed [1-3].
Bare metal stents (BMS) were developed to prevent abrupt artery closure due to recoil or dissection following balloon angioplasty and they succeeded in doing so. Acute closure has been reduced from 2 to 10 percent with PTCA alone to <1 percent in the stent era. In the stent era, PCI became safer with low rates of periprocedural myocardial infarction and emergency CABG.
As a result, stenting became the standard of care for PCIs, with balloon angioplasty alone being used only in situations where a stent could not be delivered to the targeted lesion. With refinement of stent design and implantation technique, the rate of clinically-indicated target lesion revascularization at one year after BMS placement fell to between 10 and 20 percent [4-6]. The rate has fallen further with the placement of drug-eluting stents in most patients. (See "Intracoronary stent restenosis", section on 'Incidence of restenosis'.)
The types of stents, issues related to stent deployment, periprocedural medication use, and a few related topics will be reviewed here. Issues related to antithrombotic therapy, complications of stenting, the efficacy of drug-eluting stents, and the use of stenting in specific coronary lesions are discussed separately. (See "Antithrombotic therapy for elective percutaneous coronary intervention: Clinical studies" and "Periprocedural complications of percutaneous coronary intervention" and "Drug-eluting intracoronary stents: General principles".)
TYPES OF STENTS
There are a variety of types of intracoronary stents [7,8]. In general, stents can be characterized according to material composition, thickness of struts, and whether or not they are capable of eluting drugs for local delivery (table 1). Stent design may also be specific for certain indications such as small (<2.5 mm diameter) vessels or lesions involving a bifurcation of a main vessel and side branch.
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- TYPES OF STENTS
- INDICATIONS FOR STENTING
- TECHNICAL ISSUES
- Optimal stenting
- - Predilation
- - Direct stenting without predilation
- - High pressure balloon dilation
- - IVUS
- - Optical coherence tomography
- - Coronary flow reserve measurements
- ADJUNCTIVE MEDICAL THERAPY
- Antithrombotic therapy
- Statin therapy
- - Before PCI
- - After PCI
- Restenosis versus stent thrombosis
- TIMING OF DISCHARGE
- SAFETY OF MRI
- ANTIMICROBIAL PROPHYLAXIS
- RISK OF EARLY NONCARDIAC SURGERY
- INFORMATION FOR PATIENTS