From metallic cages to transient bioresorbable scaffolds: change in paradigm of coronary revascularization in the upcoming decade?

Abstract

Drug-eluting bioresorbable scaffolds (BRSs) may in the near future change drastically the landscape of percutaneous coronary revascularization.1 In 1977, when Andreas Gruentzig introduced the concept of percutaneous transluminal coronary angioplasty, the most feared enemy of the operators was acute occlusion of the dilated lesion due to a combination of elastic recoil and intimal and medial dissection, sometimes aggravated by intraparietal haematoma ( Figure 1 ).2 Surgical standby was a sine qua non condition for the safe performance of the percutaneous treatment. At short term, proliferative neointima and constrictive remodelling could dissipate the transient benefit of the therapeutic dilatation of the stenosis. However, in the case of favourable healing following the barotrauma, late lumen enlargement, plaque regression, and vessel remodelling could occur and be modulated by change in life style, preventive medicine, and pharmacological anti-atherosclerotic agents.3 Figure 1 This schematic illustration depicts the evolution of percutaneous coronary revascularization from balloon angioplasty (BA), bare-metal stents (BMS), and drug-eluting metallic stents (DES) to vascular reparative therapy (VRT). ‘+’ implies prevented or not restricted, while ‘−’ implies not prevented, or restricted. NA, not applicable because of the absence of stent; ST, stent thrombosis. In 1986, the introduction of metallic scaffolds was initially perceived as an ad hoc solution to the problem of acute vessel occlusion ( Figure 1 ).4–6 But the implantation of the metallic endoluminal prosthesis in a thrombogenic milieu was considered as a double-edged sword. (‘The bailout stent. Is a friend in need always a friend indeed?’7) Nevertheless, scaffolding dissected post-balloon dilatation with a metallic mesh …