Choosing the Right Coronary Stent: Bare Metal vs. Drug-Eluting

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• Key Factors in Stent Selection
• Evolution of Stent Technology
• Dual Antiplatelet Therapy Considerations
• Indications for Bare Metal Stents
• Preferences for Drug-Eluting Stents
• Future Stent Developments
• Full Transcript

Key Factors in Stent Selection

Choosing between a bare metal stent and a drug-eluting coronary artery stent involves several critical patient factors. Dr. Jeffrey Popma, MD, explains that anticoagulation therapy limits, pending surgical procedures, and the diameter of the coronary artery are all major considerations. The decision is not one-size-fits-all and requires careful clinical judgment. Dr. Anton Titov, MD, highlights the ongoing controversy in optimal stent selection for different coronary artery disease presentations.

Evolution of Stent Technology

Coronary stent technology has advanced dramatically since its early days. Dr. Jeffrey Popma, MD, describes the initial Taxus and Cypher stents as having inflammatory polymers that necessitated long-term dual antiplatelet therapy. This older technology carried a significant risk of late stent thrombosis, particularly after patients discontinued therapy. Modern stents feature much thinner struts and more biocompatible polymers, fundamentally changing the risk-benefit profile. These improvements have made drug-eluting stents safer and more effective than their predecessors.

Dual Antiplatelet Therapy Considerations

The required duration of dual antiplatelet therapy (DAPT) is a cornerstone of stent selection. Dr. Jeffrey Popma, MD, notes that historically, the fear of stent thrombosis upon DAPT cessation drove many physicians toward bare metal stents. This was a strategy to avoid potential bleeding complications in patients who could not tolerate long-term therapy. Today, with newer stent designs, the thrombosis risk profile has improved significantly for drug-eluting stents. However, the anticipated need to stop DAPT early, such as for surgery, remains a key factor in the decision-making process.

Indications for Bare Metal Stents

Dr. Jeffrey Popma, MD, now limits his use of bare metal stents to two specific clinical scenarios. The first is for patients with very small coronary vessels, specifically those with a diameter of 2 millimeters or smaller, as drug-eluting stents are not currently available in these sizes. The second scenario is for patients who are scheduled for a surgical procedure within the next month and can therefore only tolerate one month of dual antiplatelet therapy. In his current practice, these specific indications account for only about 5% of his stent cases.

Preferences for Drug-Eluting Stents

Drug-eluting coronary stents are now the preferred choice in the vast majority of percutaneous coronary interventions. Dr. Jeffrey Popma, MD, states that his drug-eluting stent use is approximately 95%, a reflection of their superior performance and safety with modern designs. The occurrence of stent thrombosis with contemporary drug-eluting stents may be as low as or even lower than that seen with bare metal stents. This makes them the default option for most patients requiring coronary artery stenting, provided there are no contraindications to a longer course of DAPT.

Future Stent Developments

The field of interventional cardiology continues to evolve with promising new stent technologies on the horizon. Dr. Jeffrey Popma, MD, discusses the Synergy stent, which features a bio-resorbable polymer that dissolves completely within 90 days along with its medication. Ongoing clinical trials are exploring the possibility of safely stopping dual antiplatelet therapy at the 90-day mark with this technology. Furthermore, the development of very narrow lumen drug-eluting stents is anticipated, which would further reduce the need for bare metal stents in small vessels. Dr. Anton Titov, MD, and Dr. Jeffrey Popma, MD, agree that this is an exciting and rapidly advancing area of medicine.

Full Transcript

Dr. Anton Titov, MD: Coronary artery stent technology rapidly evolves. When should a patient still get a bare metal stent instead of a drug-eluting coronary stent? Limits to anticoagulation therapy, other pending procedures, and the diameter of the coronary artery to be stented all factor in. The use of drug-eluting coronary artery stents or bare-metal stents is controversial.

In which coronary artery disease situations might bare metal stents be enough? In which situations are drug-eluting coronary artery stents preferable?

Dr. Jeffrey Popma, MD: Yes. The answer to the question about whether one should use drug-eluting coronary stents or bare metal stents has a time component to it. At what time in the cycle of our stent development is that true?

There were once the early days of coronary artery stent development. We had two stents: the Taxus and Cypher stents. Both of those stents had polymers on their surface that were inflammatory. As a result, we had to give long-term dual antiplatelet therapy.

We worried about a very high frequency of late stent thrombosis after a year, after patients would be off their dual antiplatelet therapy. So in coronary artery stent cases, we were limited by how long we could give dual antiplatelet therapy. We were always afraid of stopping it.

In those circumstances, patients might get bare metal stents rather than drug-eluting stents. It was done to avoid potential bleeding or stent thrombosis when the patient came off therapy.

Dr. Anton Titov, MD: That was coronary artery stents in the 2003–2004 timeframe. Today the equipment is much different.

Dr. Jeffrey Popma, MD: The coronary stent struts are much thinner. The polymers are much thinner and are now more biocompatible, at least in our current method of thinking. The occurrence of coronary stent thrombosis may be as good or even a little less now with drug-eluting coronary artery stents compared to bare metal stents.

Now I really limit my bare metal stent use to patients who have two-millimeter vessels or smaller. We don't have drug-eluting stents in that area. We will have very narrow lumen drug-eluting stents soon, but I don't have them now.

Or I use them in patients who I know within the next month are going to have to go off to surgery of some sort and can only be on dual antiplatelet therapy for a month.

Where we are in a grey zone now is here. We have some other clinical trials that are ongoing right now in patients with the coronary artery Synergy stent. This coronary artery stent has a bio-resorbable polymer that disappears over 90 days along with the medications eluted from the stent.

We are exploring the idea in a registry series whether or not we can stop the antiplatelet therapy at 90 days in those patients. We hope patients stay without the risk of stent thrombosis because at 90 days all that is left is a metal stent.

Dr. Anton Titov, MD: This is certainly an evolving concept.

Dr. Jeffrey Popma, MD: I would say my drug-eluting coronary artery stent use is 95%. In the 5% when I might be using bare metal stents, I have to have a good reason for using a bare metal coronary artery stent.