Off-label Use Of Drug-eluting Stents Research Articles

9-year clinical follow-up of patients with ST-segment elevation myocardial infarction with Genous or TAXUS Liberté stents

ObjectivesThis matched-cohort retrospective study investigated the long-term (9-year) safety and efficacy outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and primary percutaneous coronary intervention (pPCI) with Genous (n = 102) versus TAXUS Liberté (n = 101) stents in 2006–2008.BackgroundIn the era of off-label use of drug-eluting stents for pPCI in patients with STEMI, the use of first-generation Genous stents (endothelial progenitor cell capture stents that have a passive coating and accelerate re-endothelialization) was proposed.MethodsThe primary endpoint was 9-year major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, re-infarction, target vessel revascularization (TVR), and stroke. The secondary endpoints were the separate primary endpoint events at pre-defined time-points (in-hospital, 6 months, and yearly) and stent thrombosis. Time-dependent 9-year composite MACCE, all-cause death, and TVR were compared using Kaplan-Meier estimates and multivariate Cox regression models.ResultsPropensity score analysis confirmed the comparability of the groups. Patients in the Genous and TAXUS groups had 7 and 1 acute definitive stent thrombosis events, respectively (p<0.001). There was a trend towards higher in-hospital MACCE in the Genous group (10.8%) versus the TAXUS group (4.0%). Kaplan-Meier analysis showed that 9-year MACCE was significantly worse in the Genous than in the TAXUS group. The in-hospital, 6-month, 1-year, and 9-year mortality rates were 7.8%, 8.8%, 9.8%, and 23.5% in the Genous group and 2.0%, 3.0%, 4.0%, and 16.8% in the TAXUS group.ConclusionsHigher peri-procedural, in-hospital, and short-term mortality led to worse outcomes for first-generation Genous stents versus TAXUS Liberté stents for pPCI in STEMI. TAXUS Liberté stents had more favorable 9-year clinical outcomes.

Abstract 13108: Optimal Duration of Dual Antiplatelet Therapy after Drug-Eluting Stent Implantation for Off-Label vs. On-Label Indications

Introduction: The risks and benefits of long-term dual antiplatelet therapy (DAPT) beyond 12 months in patients receiving drug-eluting stents (DES) and with high-risk clinical and angiographic features are unclear. Hypothesis: We try to determine whether extended use of DAPT is beneficial among patients with off-label use of DES. Methods: A total of 5,045 patients were included in the DES LATE trial and stratified according to randomized treatments (aspirin-alone or dual-therapy) and whether use was standard or off-label. Off-label was defined as use in renal insufficiency, ejection fraction ≤30%, acute myocardial infarction (MI), multivessel stenting, total stent length ≥36 mm, or ostial, bifurcation, grafts, left main, restenotic, thrombus, or totally occluded lesions. The primary endpoint was a composite of death from cardiac causes, MI, or stroke at 24 months after randomization. Results: Off-label use occurred in 68.6% of all patients. Among patients with off-label use, the risk of primary endpoint at 2 years was similar between aspirin-alone and dual-therapy group (2.6% vs. 3.1%; hazard ratio: 0.89; 95% confidence interval: 0.59 to 1.34, P = 0.59). In addition, no significant differences were observed between 2 treatment groups for individual and combined risks of efficacy and safety endpoints (death, MI, stroke, stent thrombosis, repeat revascularization, or major bleeding). These findings were consistent in patients with on-label use of DES (Figure). Conclusions: Extended use of DAPT beyond 12 months was not significantly more effective than aspirin monotherapy in reducing the risk of death from cardiac causes, MI, or stroke, regardless of off-label or on-label use of DES.

Long-Term Predictors of Clinical Events after Off-Label Use of Drug-Eluting Stent beyond 1 Year

Background and ObjectivesWe evaluated the long-term outcomes and predictors of clinical events after off-label use of drug-eluting stents (DES) beyond 1 year after procedure.Subjects and MethodsA total of 518 patients who underwent DES implantation for off-label indications and did not have any major adverse cardiac events (MACE) during the first year were analyzed. The occurrence of MACE, including cardiac death, myocardial infarction (MI), stent thrombosis and target vessel revascularization, were evaluated for a median 1179 days (interquartile range 769-1541) after the first year.ResultsMajor adverse cardiac events occurred in 43 patients (8.3%) including 8 cases (1.5%) of cardiac death, 9 cases (1.7%) of MI, 24 cases (4.6%) of target vessel revascularization, and 11 cases (2.1%) of stent thrombosis. Patients with MACE had a higher serum creatinine level, higher incidence of in-stent restenosis lesion, more overlapping stents, a greater number of stents, and longer stents than did patients without MACE. Multivariate analysis revealed that serum creatinine level >1.5 mg/dL {hazard ratio (HR) 2.3, p=0.019}, stent length >33 mm (HR 2.4, p=0.035), and in-stent restenosis lesions (HR 2.4, p=0.040) were independent risk factors for MACE. Patients with DES length >33 mm had a higher incidence of MACE than those with DES length ≤33 mm (HR 2.7, log rank p=0.002).ConclusionThe risk of stent thrombosis and target vessel revascularization persisted in patients undergoing off-label DES implantation beyond 1-year follow-up. A total DES length >33 mm was a significant procedural predictor associated with the incidence of MACE.

Safety and effectiveness of drug-eluting stents in Chinese patients with coronary artery disease with off- and on-label indications: results from a single-centre registry

BackgroundOff-label use of drug-eluting stents (DES) is more common than on-label use and may be associated with a persistently higher rate of adverse angiographic and clinical outcomes.ObjectiveTo evaluate the safety...

Abstract P118: Changes in Patient Predictors of Use of Drug-Eluting Coronary Stents After FDA Warnings in Early 2007

Objective: Use of drug-eluting stents (DES) in PCI began to decline in late 2006 after release of scientific findings of higher risk of late stent thrombosis with DES. An emergency meeting of the FDA advisory panel cautioned about complications resulting from off-label use of DES. In this study, we compared early 2006 (pre-controversy) with late 2007 (post-controversy) patient predictors of use of DES vs. BMS for STEMI, NSTEMI, and stable CHD. Methods: We compared pre-controversy vs. post-controversy predictors of DES vs. BMS for STEMI (n= 9,341), NSTEMI (n=21,410) and stable CHD (n=23,495) through multivariate logistic regression analysis of hospital discharge data for Florida. Results: Throughout the study period, we observed reduced rates of DES implantation in patients with CHF (NSTEMI), cardiomyopathy (STEMI), Medicaid (STEMI and CHD), smoking (NSTEMI and CHD), medication noncompliance (STEMI, NSTEMI and CHD), and drug abuse (STEMI). Compared to the pre-controversy era, new deterrents to DES use post-controversy for STEMI patients were age &gt;75 years, atrial fibrillation (AF), anticoagulation medication (AM), and smoking; while for NSTEMI new deterrents to DES were age &gt;85 years, AF, AM, alcohol abuse and drug abuse. For stable CHD, in the pre-controversy era, patients aged 45-54 years were more likely to get DES, while those with diabetes mellitus were less likely to get DES. In the post-controversy era, new deterrents to DES use were age &gt; 75 years, CHF, AF, peripheral vascular disease, AM, chronic kidney disease, alcohol abuse, or a history of medication noncompliance. Blacks with NSTEMI were more likely to get DES (OR 1.4; 95% CI 1.03-2.01; p=0.03) in the pre-controversy era, but less likely (OR 0.7; 95% CI 0.59-0.83; p&lt;0.0001) in the post-controversy era. In contrast, the likelihood of DES implantation for blacks was significantly lower (OR 0.61; 95% CI 0.43-0.87; p=0.006) for STEMI in the pre-controversy era only and not different for stable CHD. Conclusions: In the state of Florida, the reduction in DES use post-controversy is related to older age, presence of co-morbidities like atrial fibrillation requiring additional anticoagulants and patient markers of potential non-compliance with thienopyridines (e.g. alcohol and drug abuse).

Comparison between on-label versus off-label use of drug-eluting coronary stents in clinical practice: results from the German DES.DE-Registry

Observational studies from the USA have demonstrated that off-label use of drug-eluting stents (DES) is common. Data on off-label use in Western Europe are limited. We analyzed the data of consecutive patients receiving DES prospectively enrolled in the multicenter German DES.DE registry (Deutsches Drug-Eluting Stent Register) between October 2005 and October 2006. Off-label use was defined in the presence of one of the following criteria: ST-elevation myocardial infarction, in-stent stenosis, chronic total occlusion, lesions in a bypass graft, in bifurcation or left main stem, stent length per lesion≥32mm, and vessel diameter<2.5 or>3.5mm. Overall, 4,295 patients were included in this analysis and divided into two groups: 2,366 (55.1%) received DES for off-label and 1,929 (44.9%) for on-label indications. There were substantial differences in the rates of off-label use at the participating hospitals. Patients with off-label DES more often presented with high-risk features such as acute coronary syndrome, cardiogenic shock, congestive heart failure, and more complex coronary anatomy. Among hospital survivors, the incidence of the composite endpoint of death, myocardial infarction and stroke (MACCE) (9.2 vs. 7.4%, p<0.05), and target vessel revascularization (TVR) (11.3 vs. 9.1%, p<0.05) was increased in the off-label group at the 1-year follow-up. However, in the multivariate analysis off-label use was not linked with an elevated risk for MACCE (hazard ratio 0.86, 95% confidence interval 0.62-1.18) and TVR (hazard ratio 1.05, 95% confidence interval 0.78-1.42). In clinical practice, DES was very frequently used off-label. After adjustment for confounding variables, off-label use was not associated with an increase of adverse events.

Off‐Label Use of Drug‐Eluting versus Bare Metal Stents: A Lesion‐Specific Systematic Review of Long‐Term Outcomes

The purpose of this systematic review was to evaluate differences in lesion-specific outcomes with the "off-label" use of drug-eluting stents (DES) versus bare metal stents (BMS). MEDLINE, PubMed, the Cochrane databases, and other Web were searched for studies evaluating off-label use of DES and BMS with the same characteristics. Of 1,258 abstracts or manuscripts reviewed, 112 studies were included (total N = 23,438). Studies were excluded if patients received both types of stent or no stent; lesion type was unknown; lesion-specific outcomes for ≥6 months were unavailable; or <25 patients were enrolled. Overall mortality at 6-12 months was approximately 3% for BMS and DES for off-label use. Increase in mortality was greater from 6-12 months to 2 years with BMS than with DES (3.3%-9.1%; 2.8%-4.1%); however, rates were similar at 3 years (BMS: 18.8%; DES:15.3%). Myocardial Infarction rates were similar for both types at 6-12 months (BMS: 6.5%; DES: 6.0%). Overall rates of stent thrombosis were 1.8% and 1.7% for BMS and DES, respectively. Similar or slightly lower rates of stent thrombosis were seen for most lesion types, except higher rates for small vessels for BMS (5.2%) and true bifurcation for DES (3.3%). Rates of target lesion revascularization (TLR) were 7.5% for BMS and 19.6% for DES at 6-12 months. At 2-years TLR remained lower than DES. When the combined group was compared to registry data alone, similar values were seen. Rates of mortality, myocardial infarction (MI), and stent thrombosis were similar in patients receiving BMS or DES, while TLR rates were lower in DES patients.

Long-term clinical outcome and prognosis after treatment of the first generation drug-eluting stent thrombosis

There are many reports concerning about the incidence, predictor, and the in-hospital outcomes of stent thrombosis (ST) of drug-eluting stent (DES) [ 1 Jeremias A. Sylvia B. Bridges J. et al. Stent thrombosis after successful sirolimus-eluting stent implantation. Circulation. 2004; 109: 1930-1932 Crossref PubMed Scopus (326) Google Scholar , 2 Airoldi F. Colombo A. Morici N. et al. Incidence and predictors of drug-eluting stent thrombosis during and after discontinuation of thienopyridine treatment. Circulation. 2007; 116: 745-754 Crossref PubMed Scopus (422) Google Scholar , 3 Kuchulakanti P.K. Chu W.W. Torguson R. et al. Correlates and long-term outcomes of angiographically proven stent thrombosis with sirolimus- and paclitaxel-eluting stents. Circulation. 2006; 113: 1108-1113 Crossref PubMed Scopus (621) Google Scholar , 4 Win H.K. Caldera A.E. Maresh K. et al. Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents. JAMA. 2007; 297: 2001-2009 Crossref PubMed Scopus (315) Google Scholar , 5 Ong A.T. Hoye A. Aoki J. et al. Thirty-day incidence and six-month clinical outcome of thrombotic stent occlusion after bare-metal, sirolimus, or paclitaxel stent implantation. J Am Coll Cardiol. 2005; 45: 947-953 Abstract Full Text Full Text PDF PubMed Scopus (456) Google Scholar , 6 Iakovou I. Schmidt T. Bonizzoni E. et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA. 2005; 293: 2126-2130 Crossref PubMed Scopus (2930) Google Scholar ]. However, there are limited data for the long-term outcomes of patients who have been treated for ST after DES implantation and recurrence rate of ST in real world. The purpose of the present study was to investigate the recurrence rate and the long-term outcomes of patients who successfully treated for first generation DES thrombosis.

Off-Label Use and the Spectre of Drug-Eluting Stent Thrombosis

Off-label use of drug-eluting stents (DES) occurs when the implantation takes place outside the scope of the approved label. In the case of DES, the “on-label” indications are limited to short de novo lesions in coronary arteries measuring 2.5 to 3.75 mm in diameter. As anticipated, the use of paclitaxel-eluting stents (PES) has shown excellent outcomes with low rates of target lesion revascularization at long-term follow-up in on-label indications.1 Article see p 285 However, generalization of these data to the general population is problematic, because most patients fall into the “off-label” indication, which is associated with higher periprocedural risk. Since its launch in March 2004, thanks to its demonstrated ability to decrease target lesion revascularization, indications for PES were rapidly extended to those who would benefit most from it, such as patients with diabetes, renal failure, very small vessels, very long lesions, chronic total occlusions, bifurcations, left main coronary artery disease, in-stent restenosis, multivessel disease, acute myocardial infarction, or saphenous vein graft disease. In general, the more complex the case is, the more likely the occurrence of adverse events. Accordingly, the US Food and Drug Administration (FDA) required manufacturers to follow-up patients in the original clinical trials for 5 years after implantation and conduct registry studies of consecutively enrolled new patients, to collect data on “real-world” use.2 The emergence of the adverse events logically materialized with an increased incidence of very late stent thrombosis (ST). Concerns arose about the impact of this rare complication on cardiac mortality, and the concerns of the scientific community reached their peak at the end of 2006. The article by Lasala et al3 in this issue of Circulation: Cardiovascular Interventions was born out of this surveillance program. The first Peri-Approval Registry: A Multi-Center Safety Surveillance (ARRIVE) trial was an FDA-mandated postmarketing trial …

Outcome of Drug-Eluting Versus Bare-Metal Stenting Used According to On- and Off-Label Criteria

The aim of this study was to investigate the outcome of bare-metal stents (BMS) versus drug-eluting stents (DES) after on-label as well as off-label use. DES lower restenosis rates while not influencing the risk for death and myocardial infarction when used in Federal Food and Drug Administration (FDA)-approved indications. It is debated whether the clinical results of this so-called on-label use might be extrapolated to off-label situations. The SCAAR (Swedish Coronary Angiography and Angioplasty Registry) was used to investigate the outcomes in 17,198 patients who underwent stenting with an on-label indication (10,431 BMS and 6,767 DES patients) and 16,355 patients in the context of an off-label indication (9,907 BMS and 6,448 DES patients). The patients were included from 2003 to 2005 with a minimum follow-up of 1 year and a maximum of 4 years. The analysis was adjusted for differences in baseline characteristics. There were not significant differences between on-label DES and BMS (adjusted hazard ratio: 1.02; 95% confidence interval: 0.92 to 1.13) or between off-label DES and BMS (adjusted hazard ratio: 0.95; 95% confidence interval: 0.87 to 1.04) use with regard to the incidence of myocardial infarction and death. Off-label use of DES did not lead to significant differences in the combined risk of death and myocardial infarction compared with BMS throughout the whole spectrum of clinical indications. In contemporary Swedish practice, neither on- nor off-label use of DES is associated with worse outcome than use of BMS.

AS-251: Low-Molecular-Weight Heparin versus Unfractionated Heparin in the Off-Label Use of Drug-Eluting Stents in Acute Non-ST-Segment Elevation Myocardial Infarction

AS-251: Low-Molecular-Weight Heparin versus Unfractionated Heparin in the Off-Label Use of Drug-Eluting Stents in Acute Non-ST-Segment Elevation Myocardial Infarction

Outcomes and Complications With Off-Label Use of Drug-Eluting Stents: Results From the STENT (Strategic Transcatheter Evaluation of New Therapies) Group

This study evaluates outcomes and complications in patients treated with drug-eluting stents (DES) for "off-label" indications. Drug-eluting stents have been effective in randomized trials, but their safety and efficacy for off-label indications has not been well studied. The STENT (Strategic Transcatheter Evaluation of New Therapies) Registry is the largest multicenter U.S. registry evaluating outcomes of DES. Off-label indications included ostial, left main, long, bifurcation, and in-stent restenotic lesions, saphenous vein grafts, chronic total occlusions, small or large vessels, multilesion or multivessel percutaneous coronary interventions, and ST-segment elevation myocardial infarction. Outcomes were adjusted using Cox proportional hazards regression and propensity analyses. Drug-eluting stents were used in an off-label manner in 59% of patients. The patients who received off-label treatment were more often male, had a higher incidence of prior infarction and bypass surgery, and lower ejection fractions. Off-label versus "on-label" use of DES was associated with higher rates of death, myocardial infarction, target vessel revascularization, major adverse cardiac events, and stent thrombosis at 9 months and 2 years. Off-label use of DES compared with off-label use of bare-metal stents (BMS) had lower rates of death, myocardial infarction, target vessel revascularization, and major adverse cardiac events at 9 months and 2 years and lower rates of stent thrombosis at 9 months. Off-label use of DES is associated with higher event rates compared with on-label use of DES, which is consistent with a higher risk clinical and lesion profile. However, event rates with off-label use of DES are lower compared with off-label use of BMS. Pending results from randomized trials, our data support the use of DES for off-label indications in selected patients.

Factors Associated With Off-Label Use of Drug-Eluting Stents in Patients With ST-Elevation Myocardial Infarction

Drug-eluting stents (DESs) are used in >80% of percutaneous coronary intervention (PCI) procedures; however, up to 2/3 are used for off-label indications. Factors associated with DES use in patients with ST-elevation myocardial infarction (STEMI) are not known in contemporary clinical practice. We analyzed temporal trends, geographic patterns, and sociodemographic factors associated with off-label use of DESs in patients undergoing primary PCI for STEMI from July 2004 to March 2006 in the National Cardiovascular Data Registry (NCDR). The main outcome of this study was receipt of any DES, and the candidate independent variables were sociodemographic, hospital, clinical, and procedural variables. We also analyzed temporal trends and geographic patterns for use of DESs. A total of 30,235 patients with STEMI underwent primary PCI with use of DESs (84%) or bare metal stents (16%). Adoption of DESs was rapid but varied widely as a function of geographic location. After adjusting for clinical and procedural variables, older age was associated with lower use (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.91 to 0.98), whereas white race (OR 1.14, 95% CI 1.03 to 1.27), commercial insurance (OR 1.22, 95% CI 1.11 to 1.34), and the west census region (OR 1.37, 95% CI 1.04 to 1.81) were associated with higher use of DESs. In conclusion, adoption of DESs was rapid in patients with STEMI, but geographic location and sociodemographic and hospital factors were associated with the use DESs.

A Comparison of Bare-Metal and Drug-Eluting Stents for Off-Label Indications

Recent reports suggest that off-label use of drug-eluting stents is associated with an increased incidence of adverse events. Whether the use of bare-metal stents would yield different results is unknown. We analyzed data from 6551 patients in the National Heart, Lung, and Blood Institute Dynamic Registry according to whether they were treated with drug-eluting stents or bare-metal stents and whether use was standard or off-label. Patients were followed for 1 year for the occurrence of cardiovascular events and death. Off-label use was defined as use in restenotic lesions, lesions in a bypass graft, left main coronary artery disease, or ostial, bifurcated, or totally occluded lesions, as well as use in patients with a reference-vessel diameter of less than 2.5 mm or greater than 3.75 mm or a lesion length of more than 30 mm. Off-label use occurred in 54.7% of all patients with bare-metal stents and 48.7% of patients with drug-eluting stents. As compared with patients with bare-metal stents, patients with drug-eluting stents had a higher prevalence of diabetes, hypertension, renal disease, previous percutaneous coronary intervention and coronary-artery bypass grafting, and multivessel coronary artery disease. One year after intervention, however, there were no significant differences in the adjusted risk of death or myocardial infarction in patients with drug-eluting stents as compared with those with bare-metal stents, whereas the risk of repeat revascularization was significantly lower among patients with drug-eluting stents. Among patients with off-label indications, the use of drug-eluting stents was not associated with an increased risk of death or myocardial infarction but was associated with a lower rate of repeat revascularization at 1 year, as compared with bare-metal stents. These findings support the use of drug-eluting stents for off-label indications.

Long-Term Results With the Off-Label Use of Paclitaxel-Eluting Stents

Little information is available about the results obtained with the off-label use of drug-eluting stents. Our aim was to investigate clinical findings on long-term follow-up. The study included 604 consecutive patients who received > or = 1 paclitaxel-eluting stents (PES) at our catherization laboratory between June 2003 and February 2005. Patients were divided into two groups according to whether stent use was on-label or off-label as defined by current practice. The primary study endpoints were the combination of death and non-fatal acute myocardial infarction (AMI) and the combination of death, AMI and target-vessel revascularization (TVR). Secondary endpoints were these events individually and late stent thrombosis (ST). During the median follow-up period of 34.3 months (interquartile range 8.6 months), PESs had been used off-label in the majority of patients (i.e., 464, 76.8% of the sample) and their use was associated with an increased risk of death or AMI (hazard ratio [HR]=2.2; 95% confidence interval [CI], 1.2-4) and of death, AMI or TVR (HR=1.8; 95% CI, 1.1-3). There was no significant difference in individual events (i.e., death, AMI or TVR). The group who used stents off-label had poorer clinical characteristics (i.e., older age, and higher likelihoods of previous AMI or previous revascularization and multivessel disease), as well as a higher incidence of ST (5% vs. 0; log-rank test, P=.015). The off-label use of PESs was associated with an increased risk of a combined clinical endpoint during long-term follow-up. Further studies are needed to determine the efficacy and safety of these devices in these settings.

Clinical Outcomes and Stent Thrombosis Following Off-Label Use of Drug-Eluting Stents

Clinical Outcomes and Stent Thrombosis Following Off-Label Use of Drug-Eluting Stents

Antiplatelet Therapy After Implantation of Drug-Eluting Stents: Duration, Resistance, Alternatives, and Management of Surgical Patients

The routine off-label use of drug-eluting stents (DESs) has been associated with a higher prevalence of stent thrombosis in clinical practice than was suggested in US Food and Drug Administration (FDA) preapproval studies. Consequently, the early identification of patients at risk for stent thrombosis has become a major goal in cardiology. Although a number of factors may be involved in DES thrombosis, the biologic cascade begins with local platelet activation and culminates in platelet aggregation, the generation of coagulation factors, the formation of a fibrin network, and the creation of a stable occlusive thrombus. Current data show that the premature discontinuation of dual-antiplatelet therapy is an important risk factor for DES thrombosis, but the occurrence of stent thrombosis in patients adhering to this drug regimen suggests that some patients are nonresponsive to clopidogrel therapy, primarily because of functional and genetic variability in the cytochrome P450 enzymes. Patients with high platelet reactivity to adenosine diphosphate (ADP) during dual-antiplatelet therapy may be at increased risk for adverse ischemic events, including stent thrombosis. Using a point-of-service assay, Price et al measured platelet function in patients treated with DESs and demonstrated that 75% of patients who developed stent thrombosis were in the lowest quartile of platelet inhibition and the highest quartile of platelet reactivity. Data from the authors' center suggest that there may be a threshold of platelet reactivity, as measured by light-transmittance aggregometry after ADP stimulation, that predicts an increased risk for stent thrombosis. Large prospective studies designed to identify which patients are at risk for stent thrombosis on the basis of platelet function testing are under way and may eventually lead to personalized antithrombotic therapy.

Off-label use of drug-eluting stents: assessing the risk

Off-label use of drug-eluting stents: assessing the risk

Off-Label Use of Drug-Eluting Stents—Reply

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Off-Label Use of Drug-Eluting Stents

Off-Label Use of Drug-Eluting Stents