For which peripheral lesions could we consider drug eluting stents?

Intimal hyperplasia is a physiologic response to wall injury and represents the essential weak point of endovascular treatment. In the coronary segment, drug eluting stents (DES) have shown their effectiveness in suppressing this response and the transfer of this technique into the peripheral vasculature was mandatory, but the available data are conflictive and necessitate critical analysis. Peripheral DES related data from randomized or non randomized trials, published or presented, have been reviewed concerning the outcome in terms of "primary patency", "clinical benefit" and "limb salvage". Further inquiry was performed concerning data from material testing. The majority of study endpoints e.g. primary patency and freedom from target lesion revascularization (TLR) comply with the coronary paradigm to prevent restenosis and the peripheral DES proved this concept on an individual basis. DES meta-analytical results remain inconclusive and could not reveal superiority of DES for clinical endpoints such as limb salvage or mortality. DES differ significantly in prevention of restenosis and occurrence of severe adverse events which does impede the clinical and economic evaluations. DES related data are conflicting and partially contradicting the widespread use of this technique. The positive effect of DES in terms of patency and freedom from TLR could not achieve an omnipresent clinical correlate. Technical challenges such as availability of appropriate device length, coating related material fatigue or particulate embolization and delayed intimalization remain an issue and mandate an individual evaluation within a blinded prospective randomized study to minimize bias.