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Cardiology
Coronary Artery Stenting
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
10 sections · 195 slides
From balloon angioplasty to the stent
- Scope of this presentation
- Origin of the term stent
- First coronary balloon angioplasty
- Landmark steps in the development of coronary stents
- Limitations of plain old balloon angioplasty
- Pathophysiology of restenosis after balloon injury
- Continuing role of the coronary balloon
- First metallic scaffolds and their designs
- Two pitfalls that emerged with stenting
Fundamentals of stent design
- Principles governing coronary stent design
- Short-term efficacy principles of coronary stents
- Practical design requirements
- Stainless steel as a stent material
- Cobalt-chromium alloy
- Platinum-chromium alloy
- Strut thickness and endothelial healing
- Ultrathin versus thin struts: the 2024 meta-analysis
- How stents are manufactured
- Closed-cell versus open-cell design
- Design elements of balloon-expandable stents
- Consequences of cell geometry
Indications for percutaneous coronary intervention
- Scope of indications for PCI
- When a stent is not used
- COURAGE trial
- ORBITA and ISCHEMIA trials
- 2023 guideline recommendation in chronic coronary disease
- Anatomic subsets that favour bypass surgery
- SYNTAX and FREEDOM trials
- Where PCI is preferred despite complex anatomy
- Timing of PCI in acute coronary syndromes
- Selecting the early invasive strategy in NSTE-ACS
- Choice of device in acute coronary syndrome
- Pooled results of COMFORTABLE-AMI and EXAMINATION
- Coronary disease found in asymptomatic patients
Modern balloon angioplasty
- Role of the balloon in contemporary PCI
- Low-profile balloons
- Ultra-high-pressure balloons
- Cutting and scoring balloons
- Lithotripsy and specialised balloons
- Balloon classes, devices and starting sizes
- Balloon classes, devices and starting sizes (continued)
- Indications for each balloon device
- Indications for each balloon device (continued)
- Outcomes and complications of balloon angioplasty
- Drug-coated balloons
- BENESTENT and STRESS: stents replace the balloon
Bare-metal stents
- Bare-metal stents and intimal hyperplasia
- Stent design and vascular injury
- Randomised comparisons among bare-metal stents
- Ceiling of bare-metal stent performance
Drug-eluting stent fundamentals
- Basic components of a coronary stent
- Three components of a drug-eluting stent
- Durable versus bioresorbable polymer
- Strut geometry governs drug delivery
- Layers of the stent coating
- Structure of the drug-eluting stent coating
- Mechanisms of controlled drug release
- Profile of an ideal antirestenotic drug
- Drug physicochemistry and wall distribution
- Mechanism of the limus family
- How a limus drug stops neointimal proliferation
- Polymer-free drug release
- Reservoir technology and the drug-filled stent
Drug-eluting stent families
- Sirolimus and the Cypher stent
- Efficacy and withdrawal of the Cypher stent
- Contemporary sirolimus-eluting platforms
- Orsiro sirolimus-eluting stent
- BIOFLOW-II and BIOSCIENCE
- BIONYX and Ultimaster
- Trials and registries supporting the Orsiro stent
- Trials and registries supporting the Orsiro stent (continued)
- Trials and registries supporting the Orsiro stent (continued)
- Status and primary endpoints of the Orsiro trials
- Status and primary endpoints of the Orsiro trials (continued)
- Status and primary endpoints of the Orsiro trials (continued)
- Paclitaxel: mechanism of action
- Taxus stent and its trial evidence
- Why paclitaxel left coronary practice
- Everolimus: chemistry and platforms
- Xience everolimus-eluting stent
- Everolimus versus bare-metal stents
- Network meta-analyses of everolimus stents
- Promus Element and longitudinal deformation
- Synergy bioabsorbable polymer stent
- EVOLVE I and EVOLVE II
- SENIOR and EVOLVE Short DAPT
- Zotarolimus and the Endeavor stent
- Resolute zotarolimus-eluting stent
- Resolute versus everolimus stents
- Resolute Onyx
- Stents with short dual antiplatelet indications
- Biolimus A9: chemistry and platforms
- BioMatrix biolimus-eluting stent trials
- Nobori biolimus-eluting stent
- BioFreedom polymer-free stent
- LEADERS FREE and SORT OUT IX
- Novolimus-eluting stents
- EXCELLA II and the place of novolimus
- Amphilimus-eluting Cre8 stent
- Trial evidence for the amphilimus stent
- Biodegradable versus durable polymer: the evidence
- Durable-polymer stents: drug, maker and generation
- Durable-polymer stents: platform, struts and polymer
- Trials supporting each durable-polymer stent
- Taxus paclitaxel-eluting stent
- Cypher sirolimus-eluting stent
- Promus Element and Premier stent
- Xience everolimus-eluting stent
- Resolute zotarolimus-eluting stent
- Resolute Onyx stent
- Endeavor zotarolimus-eluting stent
- Biodegradable-polymer and polymer-free stents: drug and maker
- Biodegradable-polymer and polymer-free stents: drug and maker (continued)
- Biodegradable-polymer and polymer-free stents: platform and coating
- Biodegradable-polymer and polymer-free stents: platform and coating (continued)
- Trials behind each biodegradable-polymer stent
- Trials behind each biodegradable-polymer stent (continued)
- Yukon sirolimus-eluting stent
- Synergy everolimus-eluting stent
- Orsiro sirolimus-eluting stent
- DESyne novolimus-eluting stent
- Combo dual-therapy stent
- MiStent sirolimus-eluting stent
- Ultimaster sirolimus-eluting stent
- BioMatrix Flex biolimus-eluting stent
- BioMatrix Alfa biolimus-eluting stent
- BioFreedom polymer-free stent
- BioFreedom Ultra stent
- Nobori biolimus-eluting stent
- BioMime sirolimus-eluting stent
- Supraflex Cruz sirolimus-eluting stent
- Coroflex ISAR Neo stent
- Cre8 amphilimus-eluting stent
- Chronological development of coronary stents
Novel designs and bioresorbable scaffolds
- DynamX sirolimus-eluting bioadaptor
- Three phases of the bioadaptor implant
- Trial evidence for the bioadaptor
- Rationale for bioresorbable scaffolds
- Scaffold materials and resorption times
- Absorb BVS versus everolimus-eluting stents
- Five-year individual patient meta-analysis
- Withdrawal of the Absorb scaffold
- DREAMS 3G magnesium scaffold
- Covered stents
- Novel stent designs: device, drug and manufacturer
- Novel stent designs: platform, struts and polymer
- Trials supporting the novel stent designs
- DynamX bioadaptor implant
- REVA and ReZolve bioresorbable scaffolds
- Absorb bioresorbable vascular scaffold
- DREAMS 3G magnesium scaffold
- PK Papyrus covered stent
Anatomical and clinical scenarios
- Factors weighed before any PCI
- Abrupt or threatened closure after balloon angioplasty
- Left main coronary disease
- Percutaneous treatment of left main disease
- Choosing between PCI and surgery for left main disease
- Multivessel disease and diabetes
- Stent choice in diabetes
- Chronic total occlusion
- Saphenous vein graft intervention
- Device choice in vein graft intervention
- Bifurcation lesions
- PCI in cardiogenic shock
- Renal dysfunction
Summary
- Key points on design and materials
- Key points on drug and polymer
- Key points on patient selection
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- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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