The infamous coronary stent saga

Abstract

Against all odds, as a foreign body in a coronary artery was considered too thrombogenic, coronary artery stents have become a standard feature of percutaneous coronary intervention (PCI). After initial reluctance to employ coronary stents based on misinterpretation of thrombosis rates when stents were exclusively used for bail-out procedures, stent overuse took over quickly. Balloon angioplasty results indicated that only 25% of lesions can possibly benefit from a stent. A stent implanted in the remaining 75% of lesions is without any chance to help but carries some risk to harm. However, the risk of harm has become so small with ever improving stents that default stenting has become acceptable. Avid stent implanters argue that only 100% stenting assures that the 25% of lesions needing a stent indeed get a stent. Shortly after drug-eluting stents (DES) had been introduced, they were falsely accused of being dangerous on the ground of their higher propensity for stent thrombosis after the first year compared to bare metal stents (BMS). In fact, they had significantly fewer early stent thromboses during the first year irrespective of the extent of antiplatelet therapy. This advantage was admittedly progressively lost over the years. Subsequent generations of DES enhanced this early reduction of stent thrombosis but no longer showed that late catch-up phenomenon. These facts are ignored or misinterpreted to the present date by most physicians and all guidelines and textbooks. It was always preferable to implant a DES rather than a BMS when there was concern about stent thrombosis, be it because of need of early surgery or another impossibility to maintain double antiplatelet therapy. The respective advantage of current generation DES is overwhelming so that using a BMS is close to unethical. The most recent misconception, i.e., the need to have an absorbable stent, is also principally based on the myth of DES to be overly thrombogenic. The current absorbable stents disappear at best after a few years when the risk of a late stent thrombosis with a modern DES is virtually nil. Other reasons for absorbable stents, such as restitution of normal histology and vasomotion, easy accessibility of the stented segment for later bypass graft insertion, less stent malapposition to the vessel wall, and reduced need for antiplatelet therapy are either wrong or clinically trivial.