Stent Selection in Complex Coronary Interventions: Thinking Complex?

Abstract

https://e-kcj.org Over the past two decades, percutaneous coronary intervention (PCI) has rapidly evolved to be the mainstream therapy for revascularization in patients with coronary artery disease. Although many important milestones have been achieved, such as improved device technology, implementation of intravascular imaging for lesion selection or stent optimization, and greater understanding of drug-device interactions, the development of the drug-eluting stent (DES) has arguably been pivotal to this transformation.1) Ongoing advances in DES technology and engineering have resulted in the advent of a new generation of DESs that use antiproliferative agents with improved drug release kinetics, novel stent materials, more flexible and thinner strut platforms, and biocompatible or biodegradable polymers that offer important advantages over their first-generation counterparts. Numerous large-scale randomized trials comparing the available DESs have demonstrated excellent and reproducible long-term outcomes. As a result, contemporary DESs are generally regarded as a mature technology and have become the default PCI device for a broad range of clinical and anatomical subsets.2) Against this background, stent-based treatment has dramatically expanded its role into coronary artery lesions that have high-risk and complex features. Although a uniformly adopted consensus defining a complex PCI is lacking, anatomical features that can influence the degree of difficulty associated with PCI include true bifurcation/trifurcation disease, diffuse or multivessel disease, stenosis of tortuous vessels, chronic total occlusion, undilatable lesions accompanied by heavy calcification, and thrombotic lesions.3) The increasing age of the general population means that PCI candidates are more frequently anticipated to have such complex coronary anatomy. Indeed, the majority of patients with these challenging subsets of lesions are now successfully treated in the cardiac catheterization laboratory with the use of contemporary materials and techniques. However, following technical success, these patients remain at increased risk of midto longterm adverse ischemic events, including stent-related thrombotic complications.4) Intuitively, it may be anticipated that some stents perform better than others when complex procedural features are considered. However, limited data are available as complex PCI settings have historically been under-represented in clinical trials and registries.