Cardiac stent
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Cardiac Stents: A Comprehensive Overview
Introduction to Cardiac Stents
Cardiac stents are small, tubular devices used to keep coronary arteries open in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). These stents are crucial in treating conditions like stable angina and acute coronary syndromes (ACS) by preventing the re-narrowing (restenosis) of the arteries. There are two primary types of stents: bare metal stents (BMS) and drug-eluting stents (DES), each with distinct advantages and limitations.
Drug-Eluting Stents vs. Bare Metal Stents
Clinical Efficacy and Outcomes
Drug-eluting stents (DES) are designed to release medication over time to prevent restenosis. Studies have shown that DES, including those eluting sirolimus, paclitaxel, everolimus, dexamethasone, and zotarolimus, significantly reduce the need for repeat revascularization procedures compared to bare metal stents (BMS). However, there is no significant difference in the rates of death, myocardial infarction (MI), or thrombosis between DES and BMS.
Cost-Effectiveness
Despite their clinical benefits, DES are more expensive than BMS. The lack of significant differences in mortality and MI rates raises questions about the cost-effectiveness of DES, leading some health agencies to regulate their use based on cost considerations.
Stenting Techniques for Complex Lesions
Two-Stent vs. Provisional Stenting Techniques
For complex coronary bifurcation lesions, the systematic two-stent technique has shown better clinical outcomes compared to the provisional stenting approach. The DEFINITION II trial demonstrated that the two-stent technique significantly reduced target lesion failure (TLF), target vessel myocardial infarction (TVMI), and clinically driven target lesion revascularization (TLR) at one year. This suggests that for complex bifurcation lesions, a two-stent approach may be more beneficial.
Crush Technique vs. Provisional Side-Branch Stenting
The CACTUS study compared the crush technique with provisional side-branch stenting in true coronary bifurcations. Results indicated no significant difference in restenosis rates or major adverse cardiac events (MACE) between the two techniques, suggesting that a provisional strategy is effective and often sufficient.
Advances in Stent Materials
Biodegradable Polymer Stents
Newer-generation stents with biodegradable polymers, such as sirolimus-eluting stents, have shown superior outcomes in reducing target lesion failure compared to durable polymer everolimus-eluting stents in patients with ST-segment elevation myocardial infarction (STEMI). These stents facilitate better vascular healing and may offer improved long-term outcomes.
Self-Expanding vs. Balloon-Expandable Stents
In the context of acute myocardial infarction, self-expanding stents have demonstrated lower rates of stent malapposition compared to balloon-expandable stents. This could potentially reduce the risk of stent thrombosis and restenosis, although further studies are needed to confirm these benefits.
Long-Term Outcomes and Very-Late Stent-Related Events
Very-Late Major Adverse Cardiovascular Events (MACE)
Research indicates that very-late stent-related MACE, occurring between one and five years post-PCI, are a significant concern. These events occur at a rate of approximately 2% per year across all stent types, with no plateau in sight. This highlights the need for new strategies to improve long-term outcomes after PCI.
Conclusion
Cardiac stents, particularly drug-eluting stents, have revolutionized the treatment of coronary artery disease by significantly reducing restenosis rates. However, the choice between DES and BMS, as well as the selection of stenting techniques, must consider clinical outcomes, cost-effectiveness, and long-term safety. Advances in stent materials and designs continue to improve patient outcomes, but ongoing research is essential to address the challenges of very-late stent-related events and optimize long-term care.
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