Is It Time to Take Bare Metal Stents Off the Catheter Laboratory Shelf?

George Kassimis; Adrian P. Banning

Disclosures

Eur Heart J. 2016;37(45):3372-3375. 

In This Article

Abstract and Introduction

Introduction

Implantation of metallic stents revolutionized percutaneous coronary intervention (PCI) in the early 1990s. Coronary stents restrain dissection flaps and create a regular, usually round vessel lumen which reduces the chances of acute vessel occlusion. Stents also optimize acute lumen gain, prevent early vessel recoil, and limit the constrictive effect of late adverse vessel remodelling. However, the inevitable late increase in neo-intima formation caused by the presence of the stent required the development of drug-eluting stents (DES)-combining polymer technology with anti-proliferative drugs to improve the medium and long-term predictability of stent implantation.[1]

Drug-eluting stents implantation necessarily attenuates the vessels healing processes which results in delayed and sometimes incomplete endothelialization. Incomplete vascular healing appears to contribute to stent thrombosis (ST) which is catastrophic and can be fatal in up to 50% of cases.[1] At the European Cardiac Society in 2006, presentation of pooled data following implantation of first-generation DES and preliminary data from the Swedish SCAAR registry raised the spectre that ST appeared to be more prevalent after DES than after bare metal stent (BMS) implantation.[2,3] Consequently, rates of DES implantation plummeted throughout the world and a perception that BMS were safer than DES was initiated. Subsequent review of longer term SCARR data subsequently showed that these initial concerns were unfounded and that long-term outcomes after DES were actually superior to those with BMS.[4] Concomitant sequential improvements in the efficacy and safety of DES have been evident[5] (Table 1), but despite this, a perceived 'niche' role for BMS has persisted. This misconception about the lower rates of ST with BMS rather than DES has been potentiated by existing Guidelines.

A recent multicentre prospective registry documented the following indications for using BMS (744 consecutive PCIs): large vessel diameter, 241 (32.4%); ST-segment elevation myocardial infarction (STEMI), 132 (17.7%); reimbursement reasons, 70 (9,4%); advanced age, 92 (12.4%); planned non-cardiac surgery within the next year, 41 (5.5%); concomitant treatment with oral anticoagulants (OAC), 84 (11.3%); increased bleeding risk, cancer, or anaemia 71 (9.5%) and anticipated poor dual antiplatelet therapy (DAPT) compliance, 13 (1.7%)[6] (Figure 1). In our opinion, objective review of the current literature suggests that all of these indications for BMS are mistaken and that each of these patients would probably have been better treated with DES.

Figure 1.

Clinical indications for potential bare metal stents use. BMS, bare metal stents; DES, drug-eluting stents; DAPT, dual antiplatelet therapy.

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