Late restenosis following sirolimus-eluting stent implantation

Incidence and predictors of early and late target lesion revascularization after everolimus-eluting stent implantation in unselected patients in japan

OBJECTIVE

The objective of this study was to clarify the incidence and predictors of early and late target lesion revascularization (TLR) after everolimus-eluting stent (EES) implantation in actual clinical practice.

BACKGROUND

Several clinical studies have reported the incidence and predictors of TLR after EES implantation. However, detailed features of early and late TLR are unknown.

METHODS

We analyzed the clinical data of patients who underwent EES implantation between January 2010 and December 2011 at 22 institutions in Japan (Tokyo-MD PCI study). Patients who underwent ischemia-driven TLR (ID-TLR) were grouped according to the number of years elapsed since stent placement, and incidence and correlations between clinical factors were analyzed.

RESULTS

Statistical analysis was performed for 1,899 patients and 2,305 lesions. The mean age was 70.0 ± 9.9 years, and the median follow-up period was 1,281 days (IQR: 762-1,440 days). The incidence of ID-TLR was 2.7% at 1 year and 5.4% at 4 years. After 2 years, the ID-TLR rates plateaued. The independent predictors of ID-TLR occurring within 2 years were hemodialysis, triple vessel disease, restenotic lesion, and ostial lesions. The independent predictors of ID-TLR between 2 and 4 years were diabetes mellitus and peripheral artery disease.

CONCLUSION

The ID-TLR rates leveled off after 2 years. Furthermore, the predictors of ID-TLR that occurred within 2 years of EES implantation differed from those that occurred later than 2 years. © 2017 Wiley Periodicals, Inc.

Incidence, time course and predictors of early vs. late target lesion revascularisation after everolimus-eluting stent implantation: a SPIRIT V substudy

AIMS

To evaluate the incidence, time course and predictors of late target lesion revascularisation (TLR) (between one and two years) as compared to early TLR (<1 year) following everolimus-eluting stent implantation in patients enrolled in the SPIRIT V study.

METHODS AND RESULTS

The SPIRIT V single-arm study enrolled a total of 2,700 patients (n=2,663 intent-to-treat) with de novo coronary artery lesions undergoing EES implantation. Patients were evaluated at 30 days, one year and two years following the index procedure. All patients who had a clinically driven TLR (not associated with stent thrombosis) were allocated to either the early or the late group. Clinical, angiographic and procedural data were recorded and predictors of early vs. late TLR were assessed by logistic regression analysis. There were no significant differences in baseline demographics and risk factors between the two groups with the exception that patients in the late TLR group were significantly older (68.5 ± 8.5 years vs. 63.5 ± 8.9 years, p=0.022). At two years, only 2.7% (70/2,562) experienced a TLR unrelated to a stent thrombosis event with 1.6% (43/2,627) occurring within one year of the index procedure and 1.1% (27/2,562) occurring between one and two years. There were no differences between the groups in terms of clinical outcomes. Age ≥70 years was the only variable which independently predicted late TLR (OR=4.80 [1.69-13.63], p=0.0032).

CONCLUSIONS

In this large registry without angiographic follow-up, early (<1 year) and late (>1 year) TLR rates were exceedingly low and thereby confirm the previous findings of randomised controlled studies. Age (>70 years) emerged as the only predictor of late TLR.

Long-term serial angiographic outcomes after sirolimus-eluting stent implantation

OBJECTIVE

We evaluated, using quantitative coronary angiography, the natural history of change that occurred in target lesions after successful sirolimus-eluting stent (SES) implantation.

BACKGROUND

Percutaneous coronary intervention with drug-eluting stents (DES) has significantly reduced the rate of repeated target lesion revascularization. However, early studies have raised concerns regarding the "late catch-up" phenomenon of DES.

METHODS

Between June 2004 and March 2007, consecutive 217 patients with 306 lesions without restenosis at early angiographic follow-up underwent late angiographic follow-up (early follow-up: 11.2 ± 2.1 months and late follow-up: 29.4 ± 5.2 months). Predictors of late catch-up were identified with univariate and multivariate regression analyses.

RESULTS

Although reference vessel diameter did not significantly change during follow-up [3.15 mm (interquartile range (IQR): 2.81-3.49 mm), 3.12 mm (IQR: 2.79-3.47 mm), and 3.08 mm (IQR: 2.76-3.46 mm) at postprocedure, and early and late angiographic follow-up, respectively; P = 0.2653], late loss (LL) significantly increased during follow-up [0.05 mm (IQR: 0.00-0.13 mm) and 0.08 mm (IQR: 0.01-0.19 mm) at early and late follow-up, respectively; P < 0.0001]. Univariate analysis showed previous intervention, adjunctive use of cutting balloon, lesion length, and progression of MLD, LL, %DS at early follow-up as predictors of late catch-up. Multivariate regression analysis identified %DS at early follow-up as a predictor of late catch-up (OR 1.076, CI 1.039-1.114, P < 0.0001).

CONCLUSION

Significant and continuous progression of neointima after SES implantation was observed in the present study. Larger LL may be a sign of late catch-up phenomenon.

Short- and long-term outcomes with drug-eluting and bare-metal coronary stents: a mixed-treatment comparison analysis of 117 762 patient-years of follow-up from randomized trials

BACKGROUND

Drug-eluting stents (DES) have been in clinical use for nearly a decade; however, the relative short- and long-term efficacy and safety of DES compared with bare-metal stents (BMS) and among the DES types are less well defined.

METHODS AND RESULTS

PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials, until March 2012, that compared any of the Food and Drug Administration-approved durable stent and polymer DES (sirolimus-eluting stent [SES], paclitaxel-eluting stent [PES], everolimus-eluting stent [EES], zotarolimus-eluting stent [ZES], and ZES-Resolute [ZES-R]) with each other or against BMS for de novo coronary lesions, enrolling at least 100 patients and with follow-up of at least 6 months. Short-term (≤ 1 year) and long-term efficacy (target-vessel revascularization, target-lesion revascularization) and safety (death, myocardial infarction, stent thrombosis) outcomes were evaluated and trial-level data pooled by both mixed-treatment comparison and direct comparison analyses. From 76 randomized clinical trials with 117 762 patient-years of follow-up, compared with BMS, each DES reduced long-term target-vessel revascularization (39%-61%), but the magnitude varied by DES type (EES~SES~ZES-R>PES~ZES>BMS), with a >42% probability that EES had the lowest target-vessel revascularization rate. There was no increase in the risk of any long-term safety outcomes, including stent thrombosis, with any DES (versus BMS). In addition, there was reduction in myocardial infarction (all DES except PES versus BMS) and stent thrombosis (with EES versus BMS: Rate ratio, 0.51; 95% credibility interval, 0.35-0.73). The safest DES appeared to be EES (>86% probability), with reduction in myocardial infarction and stent thrombosis compared with BMS. Short-term outcomes were similar to long-term outcomes, with SES, ZES-R, and everolimus-eluting stent being the most efficacious and EES being the safest stent.

CONCLUSIONS

DES are highly efficacious at reducing the risk of target-vessel revascularization without an increase in any safety outcomes, including stent thrombosis. However, among the DES types, there were considerable differences, such that EES, SES, and ZES-R were the most efficacious and EES was the safest stent.

Late in-stent restenosis after sirolimus-eluting stent implantation is related to thrombus formation-Insight from a case with IVUS, OCT, and histological findings

We experienced a case of very late in-stent restenosis of a sirolimus-eluting stent (SES) (3.0 mm × 18 mm) in the left anterior descending coronary artery in a 62-year-old man with type 2 diabetes mellitus, dyslipidemia, and hypertension. Angina pectoris recurred 39 months after the index percutaneous coronary intervention (PCI). We performed PCI with optical coherence tomography (OCT) and intravascular ultrasound (IVUS) guidance. OCT showed very eccentric low signal plaque with a high signal thin cap on the delayed healing stent struts without intimal coverage. IVUS showed that the plaque was eccentric and hypoechogenic with a "black hole appearance." We used a filter wire (Filtrap™, Nipro, Osaka, Japan) to prevent distal embolism. Filter no-reflow occurred after predilatation. We deployed a paclitaxel-eluting stent followed by postdilatation. After aspiration and Filtrap™ withdrawal, thrombolysis in myocardial infarction 3 flow was obtained. Histopathological analysis revealed that the main tissue was composed of fibrin deposits with scarce inflammatory cells and proteoglycans. This case revealed that fibrin formation is related to very late in-stent restenosis and OCT and IVUS characteristics of this case are shown.

Five-year follow-up of the Sirolimus-Eluting Stents vs Vascular Brachytherapy for Bare Metal In-Stent Restenosis (SISR) trial

OBJECTIVES

The aim of this study was to evaluate the 5-year clinical safety and efficacy outcomes of patients treated for in-stent restenosis of bare-metal stents (BMSs).

BACKGROUND

The SISR trial is a prospective, randomized trial that compared the safety and efficacy of sirolimus-eluting stent (SES) vs vascular brachytherapy (VBT) for the treatment of BMS in-stent restenosis.

METHODS

A total of 384 patients with BMS in-stent restenosis were randomized to treatment with SES (n = 259) or VBT (n = 125) and were followed for 5 years.

RESULTS

At 5 years, the rates of target lesion revascularization (TLR) had narrowed and were nonsignificant between the SES and VBT groups, with TLR rates of 24.7% and 31.2% (95% CI -16.3% to 2.8%, P = .179) respectively. Target vessel failure was 33.6% vs 36.8% (95% CI -13.5% to 6.7% P = .568) for SES compared with VBT. The rate of major adverse cardiac event at 5 years was 34.0% vs 36.8% (95% CI -13.1% to7.1%, P = .648) for the SES compared with VBT. There were no differences between SES and VBT in terms of survival free from TLR (72.9% vs 66.4%, log-rank P = .08) or from target vessel failure (64.4% vs 61.3%, log-rank P = .349). There were no significant differences in the rates of definite/probable stent thrombosis (5.9% vs 2.5%, 95% CI -7.9% to 1.3%, P = .182) between the 2 groups.

CONCLUSIONS

At a 5-year follow-up, no differences in safety or efficacy outcomes were observed for treatment of BMS restenosis with SES vs VBT. There were no significant differences in survival free from TLR, target vessel revascularization, or major adverse cardiac events between the 2 groups at 5 years. Sirolimus-eluting stent is a viable treatment option compared with VBT for BMS restenosis.

Serial clinical and angiographic follow-up after phosphorylcholine-coated stent implantation

The efficacy of drug-eluting stents (DES) has been proven, but concerns about late complications after DES have been raised. Polymers that do not increase inflammatory or hypersensitivity reactions which may contribute to late complications are needed for new generation DES. To evaluate the safety and efficacy of phosphorylcholine-polymer coating, we investigated serial clinical and angiographic outcomes after phosphorylcholine-coated stent placement. Seventy-five consecutive patients treated with a BiodivYsio phosphorylcholine-coated stent for de novo lesions at our institute between October 2001 and August 2002 were enrolled. Six-month follow-up angiography was performed in 71 lesions (94.7%), and angiographic restenosis was found in 19 lesions (26.8%). Target lesion revascularization (TLR) was performed in 10 lesions (14.1%). Eighteen-month follow-up angiography was performed in 58 (95.1%) of the remaining 61 lesions (excluding TLR lesions), and angiographic restenosis was found in only 3 lesions. The cumulative MACE-free survival rate was 86.3%, 83.6%, and 78.6% at 6-month, 18-month, and 8-year follow-up, respectively. There were no episodes of stent thrombosis. Late loss decreased significantly from 0.74 ± 0.40 mm (6-months) to 0.51 ± 0.46 mm (18-months) (P < 0.0001). Phosphorylcholine-coated stent implantation was associated with acceptable clinical and angiographic results. Phosphorylcholine-coating may be an ideal polymer for new generation DESs.

Restenosis after implantation of sirolimus-eluting stent begins suddenly, shows short term progression, and stops suddenly

BACKGROUND AND PURPOSE

The peak of restenosis in patients implanted with bare metal stents (BMS) is thought to be 6 months after BMS implantation, but the development of restenosis with respect to time and the peak of restenosis in patients implanted with drug-eluting stents (DES) is not known. This study aims to reveal the rate of development of restenosis with respect to time in patients implanted with DES.

METHODS

A total of 282 patients who underwent sirolimus-eluting stent (SES) implantation in native coronary arteries at our hospital were evaluated by serial quantitative angiography at 3 and 6 months, and based on the latter results, at 1 and 2 years after SES implantation. Clinical data were collected for up to 3 years.

RESULTS

Three-year follow-up data were obtained for 261 patients. The 3-year incidence of clinically driven target-lesion revascularization (TLR) was 6.1% (16/261); of the 16 cases, 5 occurred at 3-month follow-up, 7 at 6-month angiographic follow-up, and 1 at 1-year follow up, respectively. While minimum lumen diameter (MLD) of these vessels that underwent TLR at 6 months decreased rapidly after the 3-month angiographic follow-up, MLD of the vessels with 50-70% stenosis at 6-month angiographic follow-up was almost unchanged at 1-year angiographic follow-up; however, 3 lesions required late (i.e. beyond 1 year) revascularization.

CONCLUSIONS

It is difficult to predict SES restenosis by angiography. SES restenosis begins suddenly, shows short-term progression, and stops suddenly. However, treatment of de novo coronary stenosis with SES is associated with a sustained clinical benefit and a very low incidence of TLR.

Late restenosis following sirolimus-eluting stent implantation

OBJECTIVES

This serial angiographic study evaluated the incidence and predictors of late restenosis after sirolimus-eluting stent (SES) implantation.

BACKGROUND

Previous studies showed late restenosis (i.e., late catch-up phenomenon) after implantation of 7-hexanoyltaxol-eluting stents and nonpolymeric, paclitaxel-eluting stents.

METHODS

Between August 2004 and December 2006, SES implantation was performed in 1,393 patients with 2,008 lesions, in whom 8-month and 2-year follow-up coronary angiography were planned.

RESULTS

Of 2,008 lesions, 1,659 (83%) underwent 8-month follow-up angiography (8.3 ± 2.2 months). Restenosis was observed in 122 lesions (7.4%). Coronary angiography 2 years (1.9 ± 0.4 years) after SES deployment was performed in 1,168 lesions (74% of lesions without restenosis at 8-month follow-up angiography). Late restenosis was observed in 83 lesions (7.1%). There was significant decrease in minimum luminal diameter (MLD) between 8-month and 2-year follow-up (2.56 ± 0.56 mm vs. 2.35 ± 0.71 mm, p < 0.001). Multivariate analysis showed in-stent restenosis before SES implantation and MLD at 8-month follow-up as independent predictors of late restenosis.

CONCLUSIONS

Between 8-month and 2-year follow-up after SES implantation, MLD decreases, which results in late restenosis in some lesions. In-stent restenosis before SES implantation and MLD at 8-month follow-up are independent predictors of late restenosis.

Serial angiographic findings and prognosis of stent fracture site without early restenosis after sirolimus-eluting stent implantation

BACKGROUND

Stent fracture is one of the possible causes of in-stent restenosis after sirolimus-eluting stent (SES) implantation. However, long-term prognosis including late restenosis in stent fracture site without early restenosis remains unknown. The aim of this study is to investigate the risk of late restenosis at the stent fracture site without early restenosis after SES implantation.

METHODS

We divided 366 patients with 490 lesions into 2 groups with or without stent fracture based on the first scheduled follow-up coronary angiography (fracture group, 21 lesions; nonfracture group, 469 lesions). The second scheduled follow-up coronary angiography (>15 months after SES implantation) was performed in 83 patients with 124 lesions.

RESULTS

Target lesion revascularization due to late restenosis at the stent fracture site did not occur in the fracture group, but occurred in 5 lesions in the nonfracture group. At the first follow-up, minimal luminal diameter was significantly smaller and percentage diameter stenosis was significantly larger in the fracture group (1.98 ± 0.41 vs 2.52 ± 0.49 mm, P = .001 and 30.5% ± 13.1% vs 13.0% ± 8.8%, P < .0001, respectively). These differences were also present at the second follow-up (P = .01 and P = .007, respectively). In each group, there were no significant changes in minimal luminal diameter, percentage diameter stenosis, and late lumen loss between the first and second follow-up.

CONCLUSIONS

Late restenosis was not observed in stent fracture sites without early restenosis during the midterm follow-up after SES implantation.

Incidence and risk factors of late target lesion revascularization after sirolimus-eluting stent implantation (3-year follow-up of the j-Cypher Registry)

It yet has not been clarified whether there is a late catch-up phenomenon in target lesion revascularization (TLR) after sirolimus-eluting stent (SES) compared to bare metal stent (BMS) implantation. In 12,824 patients enrolled in the j-Cypher Registry, incidences of early (within first year) and late (1 year to 3 years) TLR were compared between 17,050 lesions treated with SESs and 1,259 lesions treated with BMSs. Incidences of TLR in SES-treated lesions were 5.7% at 1 year, 8.1% at 2 years, and 10.0% at 3 years, whereas those in BMS-treated lesions were 14.2%, 15.5%, and 15.5%, respectively (p <0.0001, log-rank test). Incidences of late TLR were significantly higher with SESs compared to BMSs (2.6% vs 1.4% at 2 years and 4.5% vs 1.4% at 3 years, p = 0.0007, log-rank test). A multivariable logistic regression model identified 7 independent risk factors for late TLR at 3 years after SES implantation: hemodialysis, low estimated glomerular filtration rate, ostial right coronary artery, lesion length >or=30 mm, 2 stents for bifurcation, American Heart Association/American College of Cardiology type B2/C, and vessel size <2.5 mm. Of these, 5 factors were common to those for early TLR. In conclusion, a late catch-up phenomenon was observed as indicated by the increasing incidence of late TLR after SES, but not after BMS, implantation. Risk factors for late TLR were generally common to those for early TLR.

Predictors and prognosis of stent fracture after sirolimus-eluting stent implantation

BACKGROUND

Stent fracture is a cause of in-stent restenosis (ISR) after sirolimus-eluting stent (SES) implantation, so this study investigated the incidence, predictors and prognosis of stent fracture.

METHODS AND RESULTS

The 273 consecutive patients (364 lesions) after SES implantation and who had 6-9 month' scheduled follow-up coronary angiography (CAG) were divided into groups with and without stent fracture. Deltaangle was defined as the difference in the angle in the target lesion between diastole and systole before the procedure. The incidence of stent fracture was 4.9% (18 of 364 lesions). Deltaangle in the target lesion was larger in the fracture group (28.3 +/-11.5 degrees vs 12.3 +/-9.0 degrees , P<0.0001). Independent predictors of stent fracture were Deltaangle and total stent length. The rates of binary restenosis and target lesion revascularization (TLR) were higher in the fracture group (33% vs 4.0%, P=0.0002 and 28% vs 3.5%, P=0.0007, respectively). There were no major adverse cardiac events (MACE) in the fracture group during a mean 24-month follow-up after follow-up CAG.

CONCLUSIONS

Predictors of stent fracture were Deltaangle and total stent length. Although stent fracture was associated with ISR and TLR, it was not associated with MACE during long-term follow-up.

Impact of different re-stenting strategies on expansion of a drug-eluting stent implanted to treat bare-metal stent restenosis

We used intravascular ultrasound (IVUS) to compare the expansion of drug-eluting stents (DES) implanted to treat bare-metal stent (BMS) restenosis after 3 common re-stenting strategies. A total of 80 consecutive BMS restenotic targets were re-stented either directly (n = 30, group 1) or after low-pressure (<8 atm) pre-dilation with an undersize regular balloon (n = 16, group 2) or after high-pressure (>12 atm) pre-dilation with a semicompliant balloon the same or greater diameter as the original BMS diameter (n = 34, group 3). More patients from groups 2 and 3 had diabetes mellitus. The targets in group 1 were more proximal and focal. Lesions from groups 2 and 3 were more severe. The size and deployment pressure of the DESs and the achieved angiographic results were all similar. The post-intervention minimum stent area and the percentage of expansion of DES (minimum stent area/distal reference lumen area x 100%) were, however, both significantly larger in group 3 (6.4 +/- 1.5 mm(2) in group 3 vs 5.6 +/- 1.6 mm(2) in group 1 vs 4.4 +/- 1.4 mm(2) in group 2, p <0.001; and 88 +/- 30% in group 3 vs 74 +/- 14% in group 1 vs 73 +/- 23% in group 2, p = 0.021). A post-intervention minimum stent area <5.0 mm(2) was seen in only 3 lesions in group 3 (8.8%) versus 14 in group 1 (46.7%) and 11 in group 2 (68.8%; adjusted odds ratio 0.11, 95% confidence interval 0.03 to 0.38, p <0.001). Overall, the acute lumen gain was mainly from BMS re-expansion; however, the BMS volume increased the most in group 3 (p <0.001). In conclusion, high-pressure pre-dilation leads to superior post-intervention expansion of DESs implanted to treat BMS restenosis, regardless of the original expansion because of the greater BMS re-expansion.

Durability of antirestenotic efficacy in drug-eluting stents with and without permanent polymer

OBJECTIVES

We sought to assess changes in antirestenotic efficacy of drug-eluting stents (DES) by restudying subjects at 2 time points after coronary stenting (6 to 8 months and 2 years) and to compare differences in time courses of late luminal loss (LLL) between 3 different DES platforms in use at our institution.

BACKGROUND

DES therapy is associated with low levels of LLL at 6 to 8 months. The temporal course of neointimal formation after this time point remains unclear.

METHODS

This prospective, observational, systematic angiographic follow-up study was conducted at 2 centers in Munich, Germany. Patients underwent stenting with permanent-polymer rapamycin-eluting stents (RES), polymer-free RES, or permanent-polymer paclitaxel-eluting stents (PES). The primary end point was delayed LLL (the difference in in-stent LLL between 6 to 8 months and 2 years).

RESULTS

Of 2,588 patients undergoing stenting, 2,030 patients (78.4%) had 6- to 8-month angiographic follow-up and were enrolled in the study. Target lesion revascularization was performed in 259 patients; these patients were not considered for further angiographic analysis. Of 1,771 remaining patients, 1,331 had available 2-year reangiographic data (75.2%). Overall mean (SD) delayed LLL was 0.12 +/- 0.49 mm (0.17 +/- 0.50 mm, 0.01 +/- 0.42 mm, and 0.13 +/- 0.50 mm in permanent-polymer RES, polymer-free RES, and permanent-polymer PES groups, respectively [p < 0.001]). In multivariate analysis, only stent type (in favor of polymer-free RES) predicted delayed LLL.

CONCLUSIONS

Ongoing erosion of luminal caliber beyond 6 to 8 months after the index procedure is observed following DES implantation. Absence of permanent polymer from the DES platform seems to militate against this effect.

Safety of drug-coated stents

BACKGROUND

Drug-coated (i.e., drug-eluting) stents (DES) are frequently used nowadays in the treatment of coronary artery disease given their superior antirestenotic effect and clear benefits in terms of reduction of repeat revascularizations and major adverse cardiac events. However, a number of safety concerns have been raised on DES.

OBJECTIVE

To appraise current data on the safety of DES.

METHODS

A thorough PubMed search was done for pertinent clinical reports on DES safety with the following string (updated December 2007): (drug(*) OR sirolimus OR paclitaxel) AND eluting(*) AND stent(*) AND (safety OR complication(*) OR thrombos(*) OR infarction) NOT (editorial[pt] OR review[pt]).

RESULTS/CONCLUSION

A total of 1077 citations were retrieved and appraised. The most relevant threats to DES safety were bleeding, difficulties in balloon deflation and retrieval, endothelial dysfunction and vasospasm, hypersensitivity, infection, late acquired malapposition and aneurysm formation, late restenosis, peri-procedural myocardial infarction, plaque prolapse, stent dislodgement or embolization, stent fracture, and stent thrombosis (with ensuing risk of death, myocardial infarction or arrhythmia). Of these, the most important and debated safety issue is the potentially increased risk in late stent thrombosis, which might offset the antirestenotic benefits of DES especially in patients at higher risk of thrombosis or who cannot comply with the recommended dual antiplatelet regimen. Nonetheless, further clinical studies are warranted to clarify whether these safety threats should be a concern for the large target population of patients with coronary artery disease most likely to benefit from DES implantation.

Next-generation drug-eluting stents in coronary artery disease: focus on everolimus-eluting stent (Xience V)

Percutaneous coronary revascularization has been a mainstay in the management of coronary artery disease since its introduction in the late 1970s. Bare-metal stents and, more recently, first-generation drug-eluting stents (DES), such as sirolimus-eluting (Cypher^®) and paclitaxel-eluting stents (Taxus^®), have further improved results of percutaneous coronary intervention (PCI) by improving early results and reducing the risk of restenosis. There is currently debate on the safety of these first-generation DES, given the potential for late stent thrombosis, especially after discontinuation of dual antiplatelet therapy. There are well known caveats on the performance of their respective metallic stent platforms, delivery, and dilation systems, and polymer coatings. Second-generation DES, such as zotarolimus-eluting (Endeavor^®) and everolimus-eluting stents (Xience V^®), have recently become available in the USA and/or Europe. The Xience V stent holds the promise of superior anti-restenotic efficacy as well as long-term safety. In addition, this stent is based on the Multi-link platform and delivery system. Recently available data already suggest the superiority of the Xience V stent in comparison to the Taxus stent in terms of prevention of restenosis, without significant untoward events. Nonetheless, the number of patients studied and the follow-up duration are still too limited to enable definitive conclusions. Only indirect meta-analyses can be used to date to compare the Xience V with the Cypher. This systematic review tries to provide a concise and critical appraisal of the data in support of the Xience V everolimus-eluting stent.