Bioresorbable Polymer-Coated Orsiro Versus Durable Polymer-Coated Resolute Onyx Stents (BIONYX): Rationale and design of the randomized TWENTE IV multicenter trial

Comparison of long-term clinical outcomes of bioabsorbable polymer versus durable polymer drug-eluting stents: a systematic review and meta-analysis

BACKGROUND

One million individuals in the USA die from acute myocardial infarction (MI), which currently affects 3 million people globally. The available data about the early and late outcomes of both biodegradable polymer drug-eluting stents (BP-DES) and durable polymer drug-eluting stents exhibit inconsistency. We performed a meta-analysis comparing the safety and efficacy of BP-DES with DP-DES.

METHODS

PubMed, Google Scholar, EMBASE, Cochrane, Ovid Medline, and Clinical Trials.gov databases were used to find out studies comparing BP-DES to DP-DES. All the analyses used the random-effects model.

RESULTS

A total of 18 studies were incorporated in this meta-analysis that involved 28,874 patients, out of which 11,997 received the BP Stent, and the rest of 16,578 received the DP stent. Thorough analyses revealed that the risk of all-cause death was significantly higher in the BP-DES group (5.4% vs 2.7%) (RR 1.22, p 0.02) for two years or less than two-year follow-up. For studies with more than two years of follow-up, all-cause death was 9.07% (599/6603) in BP-DES and 9.47% (531/5602) in the DP-DES group but failed to achieve statistically significant levels (RR 0.97, p 0.58).

CONCLUSIONS

The study revealed no clinically significant (P value was > 0.05) differences in all-cause death, cardiac death, target lesion revascularization (TLR), late stent thrombosis, device-oriented composite endpoint/target lesion failure (DOCE/TLF), myocardial infarction (MI), target vessel MI, target vessel revascularization (TVR), target vessel infarction (TVI) between BP-DES and DP-DES for more than two years of follow-up. Additionally, all-cause death was only outcomes which found to have a statistically significant difference for less than two years of follow-up, while remaining were statistically non-significant.

The state-of-the-art coronary stent with crystallized sirolimus: the MiStent technology and its clinical program

Drug-eluting stents (DES) have been developed over recent decades and the implantation of DES is the standard of care in contemporary percutaneous coronary intervention for patients with coronary artery disease. The MiStent sirolimus-eluting stent has several unique features; ultra-thin (64 μm) struts, a bioresorbable polymer and a controlled drug release from microcrystalline sirolimus as a reservoir embedded in the vessel wall. Results of recent clinical trials demonstrated the potential performance of this state-of-the-art DES. In the present review, we provide an overview of the development of DES, in particular the design and performance of the novel MiStent sirolimus-eluting stent from technological and clinical points of view and discuss the potentials of this new type of DES.

Single and multi-functional coating strategies for enhancing the biocompatibility and tissue integration of blood-contacting medical implants

Device-associated clot formation and poor tissue integration are ongoing problems with permanent and temporary implantable medical devices. These complications lead to increased rates of mortality and morbidity and impose a burden on healthcare systems. In this review, we outline the current approaches for developing single and multi-functional surface coating techniques that aim to circumvent the limitations associated with existing blood-contacting medical devices. We focus on surface coatings that possess dual hemocompatibility and biofunctionality features and discuss their advantages and shortcomings to providing a biocompatible and biodynamic interface between the medical implant and blood. Lastly, we outline the newly developed surface modification techniques that use lubricant-infused coatings and discuss their unique potential and limitations in mitigating medical device-associated complications.

Recent advances in the design of cardiovascular materials for biomedical applications

Biomaterials dominate the field of cardiovascular therapeutics, a multitude of which have been used to repair and replace injured heart tissue. This field has evolved beyond the simple selection of compatible materials and now focuses on the rational design of controlled structures that integrate with the cardiovascular system. However, the compatibility of these materials with the blood presents a major limitation to their clinical application. In this context, surface modification strategies can enhance blood compatibility and several recent advances in this area have emerged. This review summarizes the recent applications of biomaterials in cardiovascular therapies, the improvements in their biocompatibility and the surface modification technologies that have the potential to improve clinical outcomes.

Thin composite wire strut, durable polymer-coated (Resolute Onyx) versus ultrathin cobalt-chromium strut, bioresorbable polymer-coated (Orsiro) drug-eluting stents in allcomers with coronary artery disease (BIONYX): an international, single-blind, randomised non-inferiority trial

BACKGROUND

During the past decade, many patients had zotarolimus-eluting stents implanted, which had circular shape cobalt-chromium struts with limited radiographic visibility. The Resolute Onyx stent was developed to improve visibility while reducing strut thickness, which was achieved by using a novel composite wire with a dense platinum-iridium core and an outer cobalt-chromium layer. We did the first randomised clinical trial to assess the safety and efficacy of this often-used stent compared with the Orsiro stent, which consists of ultrathin cobalt-chromium struts.

METHODS

We did an investigator-initiated, assessor-blinded and patient-blinded, randomised non-inferiority trial in an allcomers population at seven independently monitored centres in Belgium, Israel, and the Netherlands. Eligible participants were aged 18 years or older and required percutaneous coronary intervention with drug-eluting stents. After guide wire passage with or without predilation, members of the catheterisation laboratory team used web-based computer-generated allocation sequences to randomly assign patients (1:1) to either the Resolute Onyx or the Orsiro stent. Randomisation was stratified by sex and diabetes status. Patients and assessors were masked to allocated stents, but treating clinicians were not. The primary endpoint was target vessel failure at 1 year, a composite of cardiac death, target-vessel-related myocardial infarction, and target vessel revascularisation, and was assessed by intention to treat (non-inferiority margin 2·5%) on the basis of outcomes adjudicated by an independent event committee. This trial is registered with ClinicalTrials.gov, number NCT02508714.

FINDINGS

Between Oct 7, 2015, and Dec 23, 2016, 2516 patients were enrolled, 2488 of whom were included in the intention-to-treat analysis (28 withdrawals or screening failures). 1243 participants were assigned to the Resolute Onyx group, and 1245 to the Orsiro group. Overall, 1765 (70·9%) participants presented with acute coronary syndromes and 1275 (51·2%) had myocardial infarctions. 1-year follow-up was available for 2478 (99·6%) patients. The primary endpoint was met by 55 (4·5%) patients in the Resolute Onyx group and 58 (4·7%) in the Orsiro group. Non-inferiority of Resolute Onyx to Orsiro was thus established (absolute risk difference -0·2% [95% CI -1·9 to 1·4]; upper limit of the one-sided 95% CI 1·1%; p_{non-inferiority}=0·0005). Definite or probable stent thrombosis occurred in one (0·1%) participant in the Resolute Onyx group and nine (0·7%) in the Orsiro group (hazard ratio 0·11 [95% CI 0·01-0·87]; p=0·0112).

INTERPRETATION

The Resolute Onyx stent was non-inferior to Orsiro for a combined safety and efficacy endpoint at 1-year follow-up in allcomers. The low event rate in both groups suggests that both stents are safe, and the very low rate of stent thrombosis in the Resolute Onyx group warrants further clinical investigation.

FUNDING

Biotronik and Medtronic.