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Coronary artery stents: appropriate use of adjunctive pharmacotherapy to prevent stent thrombosis
L Gruberg1, G Dangas, M B Leon
1Cardiovascular Research Foundation, Washington Hospital Center, Washington, DC 20010, USA.
Insights
Metallic stents improve coronary angioplasty, but early thrombosis led to drug trials. Optimal stent deployment and potent antiplatelet agents now reduce risks.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Biomaterials Science
Background:
- Metallic stents were first used in coronary arteries in 1986 to prevent vessel occlusion and restenosis after angioplasty.
- Initial use was associated with high rates of thrombotic stent closure, occurring weeks after implantation.
- Early antithrombotic drug trials reduced thrombosis but increased bleeding complications and hospitalization.
Purpose of the Study:
- To review the evolution of stent implantation techniques and antithrombotic strategies.
- To highlight advancements in reducing stent thrombosis and improving patient outcomes.
- To discuss the impact of improved deployment and antiplatelet therapy.
Main Methods:
- Review of historical data and clinical trials on coronary stent implantation.
- Analysis of the impact of anticoagulation and antithrombotic drug regimens.
- Evaluation of the role of intravascular ultrasound and high-pressure ballooning in stent deployment.
- Assessment of novel antiplatelet agents and stent designs.
Main Results:
- Early stent implantation faced challenges with thrombotic closure, necessitating extensive drug trials.
- Improved stent deployment techniques, including intravascular ultrasound guidance and high-pressure inflation, significantly reduced thrombosis.
- The combination of optimal stent deployment and potent antiplatelet therapy, including aspirin and glycoprotein IIb/IIIa inhibitors, has become standard practice.
- Newer stent designs and targeted therapies are under ongoing evaluation.
Conclusions:
- Coronary stent implantation has evolved significantly since its inception.
- Optimal stent deployment and advanced antiplatelet strategies are crucial for minimizing thrombotic complications.
- Continued research into novel stent designs and pharmacotherapies promises further improvements in cardiovascular interventions.
Abstract:
In 1986, the first metallic stent was implanted inside a human coronary artery in order to reduce the incidence of abrupt vessel occlusion and restenosis after percutaneous coronary balloon angioplasty. Little was known at that time regarding the adequate anticoagulation regimen needed and the initial enthusiasm was soon marred by a high rate of thrombotic stent closure that usually occurred 2 days to 4 weeks after stent implantation. Antithrombotic drugs such as heparin, aspirin (acetylsalicylic acid), low molecular weight heparins, dextran, dipyridamole and warfarin (coumadin) were incorporated in a series of trials which reduced the risk of stent thrombosis, but increased substantially the rate of bleeding complications and the length of hospitalisation. The greatest breakthrough came with the improvement in stent deployment techniques using intravascular ultrasound-guided, high-pressure balloon inflation inside the stent, and the understanding of the central role of platelet activation in stent thrombosis. These 2 factors have led to 'optimal stent deployment' with high-pressure ballooning after stent deployment and the simultaneous use of more potent antiplatelet agents in conjunction with aspirin. Newly developed selective inhibitors of the platelet glycoprotein IIb/IIIa receptor and new stent designs have also recently been integrated into clinical practice and are currently being evaluated in clinical trials.