Use and Abuse of Coronary Stenting

The introduction of the coronary stent in 1986 remains the only real asset to balloon angioplasty introduced about 10 years earlier. Unfortunately, the undeniable advantages of stenting in terms of preventing abrupt closure and reducing restenosis are not fully exploited. The prognostic benefit to be expected from judicious stenting has been given up by default stenting. Infarctions and lives saved initially by stenting are lost again by stent thrombosis after hospital discharge fraught with a mortality of about 50% by late infarctions. They do not exist after plain balloon angioplasty and are due to stent thrombosis. Because of the comfort benefit that prevails (reduced need for intervention), virtually all interventional cardiologists have subscribed to a policy of 100% stenting and are currently about to adopt active (drug eluting) stents as their default devices for it. Once more, active stents do not confer any prognostic benefit over passive stents but they further reduce restenosis and are appealing to operators and patients. Evidence based medicine condones stenting only in about 50% and active stents in may be 80%. Yet this is ignored for rather irrational reasons. I N T R O D U C T I O N Coronary stents were developed in the early eighties primarily to remedy (bail-out) abrupt vessel closure during coronary angioplasty (PCI). The first stent implantation was performed by Jacques Puel on March 28, 1986 electively in a patient with a restenosis after coronary balloon angioplasty [1]. Although reduction of restenosis had been in the back of the minds of the stent developers [1-4], scaffolding intimal flaps was the primary task [3]. The publication launching widespread clinical use of coronary stents [4], however, already put prevention of restenosis in the forefront. It had turned out that the prevention of elastic recoil by the stent more than compensated for the disadvantage of more intimal proliferation induced by the foreign body implanted upon the lacerated endothelium of the coronary lesion. B A R E S T E N T S V E R S U S B A L L O O N A N G I O P L A S T Y The initial (non-randomized) comparisons between plain balloon angioplasty and bare stents showed a marked safety advantage of the stents (Figure 1) [5,6]. Nonetheless, stenting took off slowly because of a misconception of many an interventional cardiologist. Stenting was initially used almost exclusively for salvaging complications or bad results after balloon angioplasty. This resulted in rather dismal outcomes of the stented patients [7]. One-year-results with a mortality of 8% and 24% stent occlusions were CARDIOLOGY UPDATE 2006 Swiss Cardiovascular Center Bern, University Hospital Bern, Bern,