Safety and efficacy of drug eluting stents compared with bare metal stents for saphenous vein graft interventions: A comprehensive meta-analysis of randomized trials and observational studies comprising 7,994 patients

Percutaneous coronary intervention in saphenous vein grafts after coronary artery bypass grafting: a systematic review and meta-analysis

To investigate the results of percutaneous coronary intervention (PCI) in saphenous vein grafts after coronary artery bypass grafting (CABG). Design. MEDLINE, Embase, and the Cochrane library were searched for relevant articles published between 1 January 2000 and 29 February 2020. The PICO (population, intervention, comparison, outcome) model was applied in constructing the clinical question. Two independent researchers performed the literature search. Thirty-six articles were identified and subjected to a quality assessment. The primary outcomes of the meta-analysis were long-term in-stent restenosis and long-term major adverse cardiac events (MACE). Results. In-stent restenosis was 9.4% (95% CI: 4.2-14.7%) and MACE was 35.3% (95% CI: 27-43.7%) at mean time 2.7 ± 1.0 years. The secondary outcomes were the unsuccessful PCI rate (7.7%; 95% CI: 2.9-12.5%), 30-day MACE (4.3%; 95% CI: 2.5-6.1%), and 1-year MACE (15.5%; 95% CI: 11.7-19.3%). The use of drug-eluting stents resulted in better outcomes at least in term of in-stent restenosis, while the benefit of using embolic protection devices was questionable. Conclusions. PCI of a stenosed or occluded saphenous vein graft is a challenge for interventional cardiologists, and is still associated with relatively high rates of restenosis, MACE, and procedural failure. All efforts to enhance the results are warranted, including improved quality of the venous grafts used during CABG.

Long-term outcomes of percutaneous coronary interventions within coronary artery bypass grafts

INTRODUCTION

The long-term outcomes of percutaneous coronary interventions (PCIs) within coronary artery bypasses are still poor as compared to those within native coronary arteries. Thus, we aimed to assess predictors of long-term clinical outcomes after PCIs of coronary bypasses.

MATERIAL AND METHODS

We enrolled 194 patients after PCIs of coronary artery bypasses at the mean age of 69.5 ±8.3 years (73.2% male). The primary study endpoint was a combination of target-vessel revascularization (TVR), target-lesion revascularization (TLR), myocardial infarction (MI), stroke, coronary artery bypass grafting (CABG) and death. The mean follow-up was 964 ±799.1 days and was completed among 156 patients. Multivariate analysis was used to assess determinants of study endpoints during follow-up. Moreover, we compared survival curves according to the type of PCI and presence of anti-embolic protection.

RESULTS

The primary endpoint of the study occurred in 59.7% of patients after the mean time of 669.6 ±598.7 days. The TVR occurred in 37.9% of individuals, TLR in 24.2%, MI in 26.3%, stroke in 4.2%, CABG in 2.1% and death in 30.5% of patients. In Cox multivariate analysis, PCI of two or more bypasses (p < 0.01), post-dilatation (p < 0.05) and no-reflow (p < 0.05) were the independent determinants of the primary study endpoint. No significant impact of anti-embolic protection devices on long-term outcomes was observed.

CONCLUSIONS

Percutaneous coronary interventions of two or more bypasses, post-dilatation and no-reflow are predictors of worse outcome in patients undergoing PCI within coronary artery bypass grafts.

Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

is commonly used for children undergoing hypospadias repair. However, the safety of caudal block for hypospadias repair in children is controversial in terms of surgical complications such as urethrocutaneous fistula and glans dehiscence. We sought to perform a meta-analysis to estimate the analgesic efficacy and relative complications of caudal block for hypospadias repair in children.

METHODS

We identified comparative studies of caudal block versus peripheral nerve block or no caudal block; studies were published or presented through 1 January 2018, and reports of analgesic efficacy or surgical complications of hypospadias repair in children were identified. Peripheral nerve block includes dorsal nerve penile block and pudendal nerve block. Data were abstracted from studies comparing caudal block with peripheral nerve block or no caudal block; original source data were used when available. We prespecified separate assessments of randomized controlled trials (RCTs) and observational studies given the inherent differences between types of study designs. Data from 298 patients in four RCTs and from 1726 patients in seven observational studies were included. RCT and observational data were analyzed separately.

RESULTS

In RCTs, caudal blocks (compared with peripheral nerve blocks) showed no detectable differences in terms of need for additional analgesia within 24 hours after the surgery (OR 10.49; 95% CI 0.32 to 343.24; p=0.19), but limited data showed lower pain scores 24 hours after the surgery (standardized mean difference (SMD) 1.57; 95% CI 0.29 to 2.84; p=0.02), a significantly shorter duration of analgesia (SMD -3.33; 95% CI -4.18 to -2.48; p<0.0001) and analgesics consumption. No significant differences were observed in terms of postoperative nausea and vomiting (OR 3.08; 95% CI 0.12 to 77.80; p=0.50) or motor weakness (OR 0.01; 95% CI -0.03 to 0.05; p=0.56). Only one randomized study showed that caudal blocks (compared with peripheral nerve blocks) were associated with detectable differences in urethrocutaneous fistula rate (OR 25.27; 95% CI 1.37 to 465.01; p=0.03) and parental satisfaction rate (OR 0.07; 95% CI 0.02 to 0.21; p<0.00001). In observational studies, caudal block was not associated with surgical complications in all types of primary hypospadias repair (OR 1.83; 95% CI 0.80 to 4.16; p=0.15). To adjust for confounding factors and to eliminate potential selection bias involving caudal block indication, we performed subgroup analysis including only patients with distal hypospadias. This analysis revealed similar complication rates in children who received a caudal block and in children not receiving caudal block (OR 1.02; 95% CI, 0.39 to 2.65; p=0.96). This result further confirmed that caudal block was not a risk factor for surgical complications in hypospadias repair. The direction of outcomes in all the other subgroup analyses did not change, suggesting stability of our results.

CONCLUSIONS

In RCTs, only limited data showed peripheral nerve blocks providing better analgesic quality compared with caudal blocks. In real-world non-randomized observational studies with greater number of patients (but with admitted the potential for a presence of selection bias and residual confounders), caudal blocks were not associated with postoperative complications including urethrocutaneous fistula and glans dehiscence.

Review of risk factors, treatment, and prevention of saphenous vein graft disease after coronary artery bypass grafting

Saphenous vein graft disease (SVGD) is a type of vascular disease that may develop after coronary artery bypass grafting (CABG). SVGD seriously affects the short-term and long-term effects of CABG and increases the incidence of major adverse cardiovascular events. It is very important to identify patients at greatest risk and carry out prevention and treatment measures to determine the risk factors for SVGD. Many factors contribute to SVGD when the vein is grafted into an arterial environment, such as surgery-related factors, smoking, diabetes mellitus, hyperlipidemia, and others. In this review, we discuss the risk factors for SVGD, current surgical and pharmacologic therapies with which to manage SVGD, and the prevention of SVGD.

Should We Still Have Bare-Metal Stents Available in Our Catheterization Laboratory?

The introduction of bare-metal stents (BMS) has represented a major advancement over plain old balloon angioplasty in the management of coronary artery disease. However, the high rates of target lesion revascularization associated with use of BMS have led to the development of drug-eluting stents, which require prolonged dual antiplatelet therapy due to the increased risk of late and very late stent thrombosis. The improvements in newer-generation drug-eluting stents have translated into better safety and efficacy compared with earlier generation and BMS, thus allowing shorter dual antiplatelet therapy duration. Here, we aim to provide reasons as to why we still need BMS in our cardiac catheterization laboratory.

Current State of the Art in Approaches to Saphenous Vein Graft Interventions

Saphenous vein grafts (SVGs), used during coronary artery bypass graft surgery for severe coronary artery disease, are prone to degeneration and occlusion, leading to poor long-term patency compared with arterial grafts. Interventions used to treat SVG disease are susceptible to high rates of periprocedural MI and no-reflow. To minimise complications seen with these interventions, proper stents, embolic protection devices (EPDs) and pharmacological selection are crucial. Regarding stent selection, evidence has demonstrated superiority of drug-eluting stents over bare-metal stents in SVG intervention. The ACCF/AHA/SCA American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions guidelines recommend the use of EPDs during SVG intervention to decrease the risk of periprocedural MI, distal embolisation and no-reflow. The optimal pharmacological treatment for slow or no-reflow remains unclear, but various vasodilators show promise.

Comparison of Baseline Characteristics and Inhospital Outcomes of Patients and Use of Bare Metal Versus Drug-Eluting Stents During Percutaneous Coronary Intervention 2005 to 2015 at a Single Tertiary Hospital

With steady growth in the use of drug-eluting stents (DES), the indications for bare metal stents (BMS) have significantly changed over the last decade. This study aims to describe trends in the use of BMS and the evolution of the population receiving them over the past 10 years and determine patient characteristics associated with using BMS. Consecutive patients who underwent percutaneous coronary intervention (PCI) at the Washington Hospital Center from January 2005 through March 2015 were included. Baseline characteristics and inhospital outcomes of patients who underwent PCI with BMS versus DES were compared during 2 different time periods: from 2005 to 2010 and from 2011 to 2015. Multivariable analyses were performed for each period of time to determine independent variables associated with the choice of BMS rather than DES; 20,321 patients who underwent PCI were included in the present study. The mean age was 65.0 ± 12.5 years, 65.2% were men, and 30.4% were black. BMS use peaked in 2007 (47%) but has fallen steadily since; BMS accounted for only 10% of stents used in 2015. Presentation with acute coronary syndrome or cardiogenic shock was more common in patients receiving a BMS; this was reflected in higher rates of inhospital mortality and major bleeding among patients receiving BMS versus DES. Covariables independently associated with receiving a BMS common to both time periods included black race, Hispanic ethnicity, cardiogenic shock or acute coronary syndrome, oral anticoagulation, current smoking, increasing age, lower hematocrit, and history of chronic renal insufficiency. In conclusion, there has been a precipitous decline in the use of BMS over the last decade. Newer stent technology that promises shorter duration of dual antiplatelet therapy is likely to lead to the extinction of BMS over the next decade.

Choice of Stent for Percutaneous Coronary Intervention of Saphenous Vein Grafts

Background—

There are limited data on comparison of contemporary drug-eluting stent (DES) platforms, previous generation DES, and bare-metal stents (BMS) for percutaneous coronary intervention in saphenous vein grafts (SVG). We aimed to assess clinical outcomes following percutaneous coronary intervention to SVG in patients receiving bare-metal stents (BMS), first-generation DES, and newer generation DES in a large unselected national data set from the BCIS (British Cardiovascular Intervention Society).

Methods and Results—

Patients undergoing percutaneous coronary intervention to SVG in the United Kingdom from January 2006 to December 2013 were divided into 3 groups according to stent use: BMS, first-generation DES, and newer generation DES group. Study outcomes included in-hospital major adverse cardiovascular events, 30-day mortality, and 1-year mortality. Patients (n=15 003) underwent percutaneous coronary intervention to SVG in England and Wales during the study period. Of these, 38% received BMS, 15% received first-generation DES, and 47% received second-generation DES. The rates of in-hospital major adverse cardiovascular events were significantly lower in patients treated with second-generation DES (odds ratio, 0.51; 95% confidence interval, 0.38–0.68; P <0.001), but not with first-generation DES, compared with BMS-treated patients. Similarly, 30-day mortality (odds ratio, 0.43; 95% confidence interval, 0.32–0.59; P <0.001) and 1-year mortality (odds ratio, 0.60; 95% confidence interval, 0.51–0.71; P <0.001) were lower in patients treated with second-generation DES, but not with first-generation DES, compared with the patients treated with BMS.

Conclusions—

Patients receiving second-generation DES for the treatment SVG disease have lower rates of in-hospital major adverse cardiovascular events, 30-day mortality, and 1-year mortality, compared with those receiving BMS.

Percutaneous coronary intervention strategies and prognosis for graft lesions following coronary artery bypass grafting

The purpose of this study was to compare the prognosis of graft-percutaneous coronary intervention (PCI) and native vessel (NV)-PCI, drug-eluting stents (DESs) and bare-metal stents (BMSs) for the treatment of graft lesions following coronary artery bypass grafting (CABG), and to determine the risk factors for major adverse cardiac events (MACEs). A total of 289 patients who underwent PCI following CABG between August 2005 and March 2010 were retrospectively analyzed. The effects on survival were compared among patients who underwent NV- and graft-PCI, and DES and BMS implantation. Additionally, the risk factors for MACEs following PCI for graft lesions were analyzed. The findings showed that MACE-free and revascularization-free survival rates were significantly higher in the NV-PCI group compared with those in the graft-PCI group. There were 63 cases (29.0%) of MACEs in the DES group and 25 cases (52.1%) in the BMS group. In patients undergoing NV-PCI, the DES group had significantly fewer MACEs and less target vessel revascularization (TVR) than the BMS group. In patients undergoing graft-PCI, the DES group showed a tendency for fewer MACEs and a lower incidence of cardiac mortality, myocardial infarction and TVR compared with the BMS group. Diabetes, an age of >70 years and graft-PCI were independent risk factors for MACEs in patients post-PCI. It is concluded that NV-PCI has superior long-term outcomes compared with graft-PCI, and should therefore be considered as the first-line treatment for graft disease following CABG. Despite this, graft-PCI remains a viable option. DESs are the first choice for graft-PCI due to their safety and efficacy and their association with reduced mortality and MACE rate. Diabetes, older age and graft-PCI are independent risk factors for MACEs in patients post-CABG who are undergoing revascularization.

Long term outcomes of saphaneous vein graft intervention in elderly patients with prior coronary artery bypass graft

OBJECTIVES

To investigate the procedure characteristics and long term follow-up of percutaneous coronary intervention (PCI) for saphaneous vein graft (SVG) lesions in the elderly patients.

METHODS

From December 2005 to December 2011, 84 graft lesions were treated percutaneously. Seventeen were located at proximal anastomosis, 48 were located at SVG body, 19 were located at distal anastomosis. Primary endpoint was defined as major adverse cardiovascular events (MACE, composite of cardiac death, target vessel revascularization, acute myocardial infarction).

RESULTS

The graft age was 6.7 ± 4.0 years. Most anastomosis lesions (80.0%) presented within one year post coronary artery bypass grafting (CABG). Proximal anastomosis lesion had the lowest successful rate for PCI compared with graft body and distal anastomosis lesions (70.6% vs. 91.7%, 79.0%, P < 0.05). The distal embolic protection device was used in 19.1% of patients, most frequently used in body graft PCI (29.2%, P < 0.01). The diameter of the stent was smallest in distal anastomosis group (2.9 ± 0.4 mm, P < 0.05). The highest post dilatation pressure was required in the proximal anastomosis (17.8 ± 2.7 atm, P < 0.05). The patients were followed up for 24.3 ± 16.9 months. MACE occurred in 18.57% of patients. Incidence of MACE was highest among proximal anastomosis PCI (47.1% vs. body graft PCI 16.7%, distal anastomosis PCI 21.1%; P < 0.05). Old myocardial infarction was the predictive factor for the poor clinical outcomes (P = 0.04).

CONCLUSIONS

PCI of SVG lesions is feasible with lower success rate. PCI of ostial graft anastomosis lesions had the lowest procedure success rate and highest MACE rate compared with graft body and distal anastomosis lesions. Old myocardial infarction was a predictive factor of poor outcomes.

An update on coronary bypass graft intervention

Coronary artery bypass grafting (CABG) remains one of the most common surgical procedures. In spite of great advancements like arterial grafts and off-pump bypass procedure, recurrent ischaemia may ensue with the lesions of the graft. Early postoperative ischaemia (<30 days) is due to graft occlusion or stenosis, and percutaneous coronary intervention (PCI) is frequently feasible. Late postoperative ischaemia (>3 years) is most often due to a saphenous vein graft (SVG) lesion. Multiple diseased grafts, reduced left ventricular function, and available arterial conduits favour repeat CABG, whereas, a patent left internal mammary artery to left anterior descending favours PCI. Embolic protection reduces atheroembolic myocardial infarction during PCI of SVG and should be routinely used in treatment of SVG lesions. A variety of vasodilators may reduce the risk of or mitigate the consequences of no-reflow. Drug-eluting stents reduce restenosis in SVG grafts, and have become the default strategy for many interventionalists.

Comparison of first- and second-generation drug-eluting stents in saphenous vein grafts used as aorto-coronary conduits

Saphenous vein grafts (SVGs) are prone to an aggressive atherosclerotic process, and the efficacy of drug-eluting stents (DES) in treating this is still debated. In recent years, second-generation DES have been increasingly used in SVG intervention. The main objective of this study was to compare midterm clinical outcomes between first- and second-generation DES in SVGs because data regarding the use of second-generation DES in SVG are lacking. Patients treated with first-generation DES (127 patients with 143 lesions) and those treated with second-generation DES (84 patients with 100 lesions) were included in the study. Major adverse cardiac events, defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization, as well as target vessel revascularization and target lesion revascularization separately, were evaluated at 30-day, 12-month, and 18-month follow-up. Baseline characteristics were similar between the 2 groups. Older grafts were treated with second-generation DES (11.6 ± 5.3 vs 14.3 ± 6.0 years, p = 0.001). Stent length was longer in the first-generation group (34.1 ± 25.1 vs 30.5 ± 19.4 mm, p = 0.006), and maximum balloon diameter was smaller in the second-generation group (3.42 ± 0.42 vs 3.30 ± 0.41 mm, p = 0.003). Embolic protection device use was higher in the second-generation DES group (55.2% vs 72.0%, p = 0.012). At 18-month follow-up, rates of major adverse cardiac events, target vessel revascularization, and target lesion revascularization for the first- and second-generation groups were 24.4% versus 20.2% (p = 0.479), 18.1% versus 14.2% (p = 0.465), and 15.0% versus 10.7% (p = 0.373), respectively. In conclusion, second-generation DES are at least comparable with first-generation DES with regard to clinical outcomes at midterm follow-up.

Drug-Eluting Stents Versus Bare Metal Stents in Saphenous Vein Graft Intervention

Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) is associated with higher adverse event rates, lower procedural success, and inferior longterm patency rates compared with native vessel PCI. The ability to comply with dual antiplatelet therapy, and whether the patient will need an interruption in dual antiplatelet therapy, should be considered when deciding whether to implant a drug-eluting stent (DES) or bare metal stent (BMS) in an SVG. DES should be used for SVG PCI because they seem to reduce target vessel revascularization. This article reviews the evolution and contemporary evidence regarding use of DES versus BMS in SVG PCI.

Degenerated Saphenous Vein Graft Intervention: Should We Target the Native Vessel instead?

Coronary interventions of degenerated saphenous vein grafts (SVGs) continue to present a management challenge. Although repeat coronary artery bypass grafting (CABG) remains a significant risk factor for operative mortality, percutaneous coronary intervention (PCI) is still associated with a high risk for periprocedural events. There is a lack of consensus on the optimal treatment strategy for patients with severe stenosis of SVGs. It is imperative to review the characteristics of native versus SVG disease, risk factors for complications after SVG intervention, procedural treatment strategies important to the decision on which therapeutic strategy to follow, and measures to mitigate the risks of periprocedural complications.

Retrograde fractional flow reserve and recanalization of a chronic total occlusion of a saphenous venous graft

Chronic total occlusion (CTO) of the coronary artery represents a difficult group of lesions for percutaneous interventions. Conventionally, antegrade approach has been used to open these lesions, but recent literature provides evidence for the utility of retrograde approach in cases where initial antegrade approach is either not feasible or fails to recanalize the target vessel. This report illustrates retrograde CTO recanalization of saphenous vein graft (SVG) with fractional flow reserve utilization to determine ischemia in the territory of occluded SVG.

Anaortic, total-arterial, off-pump coronary artery bypass surgery: why bother?

Coronary artery bypass grafting (CABG) remains the standard of care for multi-vessel coronary disease. However, the increased rate of peri-operative stroke reported after surgery compared to percutaneous coronary intervention (PCI) remains of concern. Anaortic, total-arterial, off-pump coronary artery bypass (OPCAB) grafting is a technique that offers the main advantages of surgical revascularisation with a rate of stroke that is equivalent to that of PCI. Some recent trials comparing conventional on-pump CABG with OPCAB have questioned the efficacy of the off-pump technique - these are most often performed with manipulation of the ascending aorta. We review the potential benefits of the anaortic, total-arterial OPCAB technique to explain why it is being employed by an increasing number of surgeons.

Long-term safety and efficacy of drug-eluting and bare metal stents in saphenous vein grafts

BACKGROUND

Long-term safety and efficacy data of drug-eluting stents (DESs) in saphenous vein grafts (SVGs) are lacking. This study sought to compare the clinical outcomes of DES versus bare metal stents (BMS) in SVGs.

METHODS

We studied all stent implantations in SVGs in Sweden during 74 months between 2005 and 2011 registered in the Swedish Coronary Angiography and Angioplasty Registry. We evaluated outcome in patients who received DES compared with those who received BMS after adjustments for differences in clinical, vessel, and lesion characteristics.

RESULTS

Mean follow-up time was 3 years and 4 months. A total of 4,576 stents, implanted at 3,063 procedures, were included in the analysis of which 2,499 stents (54.6 %) were BMS and 2,077 (45.4%) were DES. The outcome analysis was based on 190 stent thromboses, 898 restenoses, and 523 deaths. The incidence of stent thrombosis did not differ between groups. When adjusted for baseline characteristics, including a propensity score for receiving DES, the incidence of restenosis was significantly lower with DES as compared with BMS (risk ratio 0.83, 95% CI 0.70-0.97, P = .019). There was a difference in mortality in the crude analysis between DES and BMS, and after multivariable adjustment, this difference remained statistically significant (risk ratio 0.80, CI 0.65-0.99, P = .038).

CONCLUSIONS

The use of DES compared with BMS in SVGs was associated with a significantly lower adjusted incidence of restenosis and death in this large, national, all-encompassing propensity adjusted observational study.

Clinical outcomes of percutaneous interventions in saphenous vein grafts using drug-eluting stents compared to bare-metal stents: a comprehensive meta-analysisof all randomized clinical trials

BACKGROUND

Clinical outcomes of percutaneous coronary intervention (PCI) in patients with saphenous vein grafts (SVGs) remain poor despite the use of drug-eluting stents (DES). There is a disparity in clinical outcomes in SVG PCI based on various registries, and randomized clinical data remain scant. We conducted a meta-analysis of all existing randomized controlled trials (RCTS) comparing bare-metal stents (BMS) and DES in SVGPCIs.

HYPOTHESIS

PCI in patients with SVG disease using DES may reduce need for repeat revascularization without an excess mortality when compared to BMS.

METHODS

An aggregate data meta-analysis of clinical outcomes in RCTs comparing PCI with DES vs BMS for SVGs reporting at least 12 months of follow-up was performed. A literature search between Janurary 1, 2003 and September 30, 2011 identified 4 RCTs (812 patients; DES = 416, BMS = 396). Summary odds ratio (OR) and 95% confidence interval (CI) were calculated using the random-effects model. The primary endpoint was all-cause mortality. Secondary outcomes included nonfatal myocardial infarction (MI), repeat revascularization, and major adverse cardiac events (MACE). These outcomes were assessed in a cumulative fashion at 30 days, 18 months, and 36 months.

RESULTS

There were no intergroup differences in baseline clinical and sociodemographic characteristics. At a median follow-up of 25 months, patients in the DES and BMS group had similar rates of death (OR: 1.63, 95% CI: 0.45-5.92), MI (OR; 0.83, 95% CI: 0.27-2.60), and MACE (OR: 0.58, 95% CI: 0.25-1.32). Patients treated with DES had lower rates of repeat revascularization (OR: 0.40, 95% CI: 0.22-0.75).

CONCLUSIONS

In this comprehensive meta-analysis of all RCTs comparing clinical outcomes of PCI using DES vs BMS in patients with SVG disease, use of DES was associated with a reduction in rate of repeat revascularization and no difference in rates of all-cause death and MI. Clin. Cardiol. 2012 DOI: 10.1002/clc.21984 Dr. Virani is supported by a Department of Veterans Affairs Health Services Research and Development Service (HSR&D) Career Development Award (CDA-09-028), and has research support from Merck and National Football League Charities (all grants to the institution and not individual). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Saphenous vein graft intervention

Saphenous vein grafts are commonly used conduits for surgical revascularization of coronary arteries but are associated with poor long-term patency rates. Percutaneous revascularization of saphenous vein grafts is associated with worse clinical outcomes including higher rates of in-stent restenosis, target vessel revascularization, myocardial infarction, and death compared with percutaneous coronary intervention of native coronary arteries. Use of embolic protection devices is a Class I indication according to the American College of Cardiology/American Heart Association guidelines to decrease the risk of distal embolization, no-reflow, and periprocedural myocardial infarction. Nonetheless, these devices are underused in clinical practice. Various pharmacological agents are available that may also reduce the risk of or mitigate the consequences of no-reflow. Covered stents do not decrease the rates of periprocedural myocardial infarction and restenosis. Most available evidence supports treatment with drug-eluting stents in this high-risk lesion subset to reduce angiographic and clinical restenosis, although large, randomized trials comparing drug-eluting stents and bare-metal stents are needed.

How safe and how good are drug-eluting stents?

Percutaneous transluminal coronary angioplasty revolutionized therapy for coronary artery disease. This early promise of a viable alternative to surgical treatment of coronary artery disease was thwarted by the high rates of angiographic restenosis. The advent of stenting reduced the rates of restenosis, although it was hindered by the new problem of in-stent restenosis. It was demonstrated that in-stent restenosis was the result of a new pathology in the form of neointimal hyperplasia, which was a maladaptive healing response to bare-metal stent implantation. Recently, the introduction of drug-eluting stents (DES) technology has offered a new solution to the problem of restenosis. Current evidence suggests that although DES have reduced restenosis rates, important concerns have been raised regarding increased stent thrombosis, myocardial infarction and death. The purpose of this article is to examine the efficacy and safety data of DES as highlighted in recent publications and to further discuss the biomolecular mechanisms of accelerated endothelization and stent thrombosis. In addition, we will examine some of the newer stent technologies available.