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New concepts in the design of drug-eluting coronary stents

Nature Reviews Cardiology volume 10, pages 248–260 (2013)Cite this article

Subjects

Abstract

Drug-eluting stents (DES) have revolutionized the practice of interventional cardiology over the past decade. Although their efficacy has never been called into question, concerns have been raised regarding their safety, particularly with respect to very late stent thrombosis. These valid concerns have prompted extensive research into improving stent safety, with particular interest in modifying the permanent polymer used on first-generation DES. Subsequently, various new types of coronary stent have been developed, including DES with biocompatible polymers, DES with biodegradable polymers, polymer-free DES, and completely bioresorbable scaffolds. Some of these new DES are already available in clinical practice, and others are currently undergoing clinical evaluation. Improvements in stent performance have made detecting statistically robust and clinically relevant differences between contemporary devices difficult. The wide array of available stents enables the choice of device to be tailored to the individual patient.

Key Points

  • Long-term safety concerns with first-generation drug-eluting stents (DES) were the major driver for modifications to the stent platform, stent polymer, and the eluted antiproliferative drug

  • Second-generation DES have been shown to be both safer and at least as efficacious as first-generation devices

  • Biodegradable polymer stents have been shown to be a safe and efficacious alternative to conventional durable polymer DES

  • Bioresorbable vascular scaffolds are an emerging technology, which hold promise to improve the safety of coronary stents

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Figure 1: Temporal evolution in the incidence of stent thrombosis according to adjunct phamacotherapy, stent type, (bare-metal or drug-eluting), and percutaneous coronary intervention technique.
Figure 2
Figure 3: Mechanism of action of the macrocylic lactones (biolimus A9, everolimus, myolimus, novolimus, sirolimus, and zotarolimus), which inhibit mTOR resulting in cell cycle arrest, and paclitaxel, which inhibits smooth muscle cell proliferation through the stabilization of microtubules, thereby preventing cell division.
Figure 4: Temporal change in concentration of BA9 and PLA polymers on the BioMatrix Flex® stent (Biosenors Europe S.A., Morges, Switzerland).
Figure 5: Rates of TLR and late lumen loss at 12-month and 24-month follow-up in the ISAR-TEST 3 trial.77,78
Figure 6: Metabolism of PLLA, and bioabsoprtion curves for bioabsorbable materials.

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  1. Department of Cardiology, East Lancashire NHS Trust, Haslingden Road, Blackburn, BB2 3HH, Lancashire, UK

    Scot Garg

  2. Department of Cardiology, Thoraxcentre, Erasmus MC, 's Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands

    Christos Bourantas & Patrick W. Serruys

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Garg, S., Bourantas, C. & Serruys, P. New concepts in the design of drug-eluting coronary stents. Nat Rev Cardiol 10, 248–260 (2013). https://doi.org/10.1038/nrcardio.2013.13

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