Two-year clinical outcomes of different drug-eluting stents with different polymer coating strategies in coronary artery heart disease: A multi-centre, randomised, controlled clinical trial

Individualizing Medicinal Therapy Post Heart Stent Implantation: Tailoring for Patient Factors

The field of cardiovascular medicine is undergoing a transformative shift towards personalized medicinal therapy, particularly in the context of post stent implantation. This narrative review explores the significance, challenges, and future directions of individualized treatment strategies for patients with coronary stents. The review highlights the pivotal role of personalized approaches in optimizing treatment efficacy and minimizing adverse events. Real-world clinical studies and trials underscore the importance of tailoring antiplatelet therapy based on platelet function testing, genetic testing, and risk scoring. These studies reveal that personalized medicinal treatment improves clinical outcomes by balancing preventing thrombotic events and mitigating bleeding risks. Challenges, including cost, test availability, patient adherence, and ethical considerations, are discussed in depth, shedding light on the complexities of implementing personalized approaches. Technological advancements, including omics data integration, artificial intelligence, and big data analytics, shape the future of personalized medicinal therapy. These tools enable precise pharmacogenomic selection of medications and the development of integrated risk-scoring systems. Patient engagement and education are also central, with empowered patients and remote monitoring contributing to collaborative decision-making. In conclusion, the narrative review underscores that personalized medicinal therapy post stent implantation holds immense promise for revolutionizing cardiovascular care. By embracing a comprehensive approach that considers genetics, clinical factors, and patient preferences, healthcare providers can optimize treatment outcomes and improve patient quality of life. The evolving landscape of personalized medicine offers a glimpse into a future where tailored treatment strategies become the cornerstone of precision cardiovascular care.

Clinical Outcomes of Polymer-Free Versus Polymer-Coated Drug-Eluting Stents in Patients With Coronary Artery Disease: A Systematic Review and Meta-Analysis

Drug-eluting stents have transformed the treatment of coronary artery disease (CAD), and there are two types: polymer-free and polymer-coated stents. Polymer-free stents have a coating that is quickly absorbed by the body, whereas polymer-coated stents have a coating that remains on the stent surface. This meta-analysis and systematic review aimed to compare the clinical outcomes of these two stent types in patients with coronary artery disease. The literature and abstracts from significant databases were reviewed to compare polymer-free drug-eluting stents (PF-DES) and polymer-coated drug-eluting stents (PC-DES) for the treatment of coronary artery disease (CAD). The primary efficacy endpoints of the study were all-cause mortality and deaths from cardiovascular and non-cardiovascular causes. Among the secondary outcomes were incidences of myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), stent thrombosis, stroke, and major adverse cardiovascular events (MACEs). In terms of the primary outcomes, the combined analysis revealed a marginally lower risk of all-cause mortality (relative risk, RR (95% CI) = 0.92 (0.85, 1.00), p = 0.05, I² = 0%) with the use of PF-DES versus PC-DES. Nonetheless, there was no significant difference in cardiovascular mortality (RR (95% CI) = 0.97 (0.87, 1.08)) or non-cardiovascular mortality (RR (95% CI) = 0.87 (0.69, 1.10), p = 0.25, I² = 9%) between the groups. Furthermore, univariate meta-regression revealed that male gender and prior myocardial infarction were independently associated with an increased risk of all-cause mortality and cardiovascular disease. According to the current meta-analysis, no statistically significant differences existed in PF-DES and PC-DES outcomes. More extensive research is needed to investigate these findings further and establish their validity.

Drug-eluting stents for the treatment of coronary artery disease: A review of recent advances

INTRODUCTION

Percutaneous coronary intervention is a widely used procedure for the treatment of coronary artery disease to relieve narrowing or occlusion and improve blood supply. Although only balloon angioplasty was performed in the early period, coronary stents were developed later and coronary drug-eluting stents were introduced to decrease in-stent restenosis, which is related to the proliferation and migration of vascular smooth muscle cells.

AREAS COVERED

The drug-eluting stents are composed of a metallic or polymeric platform, specific drug, and polymers or coating for drug release. In this article, the recent advances in drug-eluting stent technologies for the treatment of coronary artery disease and adjunctive antiplatelet therapy after drug-eluting stent implantation will be reviewed.

EXPERT OPINION

The need for further advances in drug-eluting stents or fully bioresorbable coronary scaffolds still exists to improve patient survival or clinical outcomes. The use for different actions or of combinations of drugs with several actions can be potential. Technological refinement and progress in manufacturing to improve mechanical integrity are needed, particularly for fully bioresorbable scaffolds. For antiplatelet therapy after stenting, clinical bleeding reduction strategies, such as a shortened duration of dual-antiplatelet therapy, are in progress.

Safety and efficacy of the polymer-free and polymer-coated drug-eluting stents in patients undergoing percutaneous coronary intervention

INTRODUCTION

The relative safety and efficacy of polymer-free (PF) versus polymer-coated (PC) drug-eluting stents (DES) in patients with angina or acute coronary syndrome (ACS) undergoing percutaneous coronary intervention has received limited study.

METHOD

Digital databases were queried to identify relevant studies. Major adverse cardiovascular events (MACE) and secondary outcomes were compared using a random effect model to calculate unadjusted odds ratios (OR).

RESULTS

A total of 28 studies consisting of 23,198 patients were included in the final analysis. On pooled analysis, there was no significant difference in the odds of MACE (OR 0.98, 95% CI 0.91-1.08) and major bleeding (OR 0.87, 95% CI 0.61-1.24) between patients undergoing PF-DES versus PC-DES. Similarly, the odds of myocardial infarction, stroke, stent thrombosis, cardiovascular mortality and need for target vessel revascularization was similar between the two groups. PF-DES was favored due to significantly lower odds of non-cardiac death (OR 0.78, 95% CI 0.68-89) and all-cause mortality (OR 0.87, 95% CI 0.80-0.95), but had a higher need for target lesion revascularization (OR 1.2, 95% CI 1.02-1.42). A subgroup analysis based on follow up duration, clinical presentation, presence of diabetes and class of eluting drugs mirrored the net estimates for all outcomes with a few exceptions. A sensitivity and meta-regression analysis showed no influence of single-study and duration of antiplatelet therapy on pooled outcomes.

CONCLUSION

In patients presenting with angina or ACS, PF-DES might be favored due to lower all-cause mortality and equal risk of ischemic adverse cardiovascular and major bleeding events compared with PC-DES.

Polymer-Free vs. Polymer-Coated Drug-Eluting Stents for the Treatment of Coronary Artery Disease: A Meta-Analysis of 16 Randomized Trials

BACKGROUND

Polymer-coating represents one of components of drug-eluting stents (DES) to have experienced a more intensive technological evolution. Polymer-free DES (PF-DES) have offered promising angiographic results, with earlier complete re-endothelization, potentially reducing the thrombotic risk and offering the option of a shorter antiplatelet therapy. However, contrasting prognostic data have been reported so far with PF-DES. Therefore, the aim of the present study was to perform a comprehensive updated meta-analysis of randomized trials (RCT) comparing the impact of PF-DES vs polymer- coated DES (PC-DES) on clinical outcome.

METHODS

Literature and main scientific session abstracts were searched for RCTs comparing PF-DES vs PC-DES for the treatment of CAD. The primary efficacy endpoint was mortality, secondary endpoints were cardiovascular death, myocardial infarction, target lesion revascularization (TLR) and stent thrombosis.

RESULTS

We included 16 randomized clinical trials, with a total of 15,689 patients, including 50.6% randomized to PF-DES. At a median follow-up of 24 months, PF-DES were associated to a significant reduction in mortality as compared to PC-DES (0.82 [0.68, 0.99], p = .03, I2 = 0%; phet = 0.93). However, no significant benefit was observed in terms of cardiovascular death or major ischemic endpoints (respectively CV death: OR [95% CI] = 0.92 [0.71, 1.18] p = .50, I2 = 0.50; phet = 0.84; MI: OR [95% CI] = 1.08 [0.90, 1.29], p = .42; I2 = 0%, phet = 0.98; TLR: OR [95% CI] = 1.02 [0.78, 1.32], p = .91; I2 = 0.63 phet = 0.0003; ST: OR [95% CI] = 0.98 [0.87, 1.10], p = .72; I2 = 0% phet = 0.64). By meta-regression analysis, the mortality benefits of PF-DES were not conditioned by the rate of diabetes mellitus or acute coronary syndromes.

CONCLUSIONS

Based on the current meta-analysis, PF-DES are associated to a significant reduction in mortality as compared to PC-DES, but not in the occurrence of major ischemic events. Future larger studies are certainly needed to further investigate and confirm our findings, especially in particular subsets of patients, such as those with high bleeding risk or acute myocardial infarction.

Polymer-free drug-eluting stents versus permanent polymer drug-eluting stents: An updated meta-analysis

BACKGROUND

Polymer-free drug-eluting stents (PF-DES) have been demonstrated comparable to permanent polymer drug-eluting stents (PP-DES) during long-term follow-up. As a critical component of drug-eluting stents, antiproliferative drugs may be a confounding factor for the results. Thus, we sought to compare the outcomes of these stents during long-term follow-up, especially in consideration of different stent platforms with the same drugs.

METHODS

A systemic search was performed to identify the related randomized controlled trials comparing PF-DES with PP-DES. Primary outcomes included short (≤1 year) and long-term (>1 year) target lesion revascularization (TLR), short-term in-stent late luminal loss (LLL) and diameter stenosis (DS). Subgroup analyses stratified by the different platforms with the same proliferative drugs were conducted in TLR, LLL, and DS. Standardized mean differences (SMDs) and risk ratios (RRs) were estimated using fixed /random effects models RESULTS:: A total of 6927 patients extracted from 12 RCTs were enrolled in the meta-analysis. No differences were observed in clinical outcomes of short-term and long-term overall mortality, myocardial infarction and stent thrombosis and angiographic outcomes of short-term in-stent LLL and DS between PF-DES and PP-DES for patients with coronary artery lesions. Nevertheless, compared with PP-DES coated with the same proliferative drugs, PF-DES had significantly increased risks of in-stent LLL (SMD, 0.49; 95% confidence interval [CI], 0.25-0.72) and DS (SMD, 0.67; 95% CI, 0.27-1.07), and long-term TLR (RR, 1.64; 95% CI 1.13-2.39). There were no significant differences in other outcomes.

CONCLUSIONS

Under the condition of using same antiproliferative drugs (paclitaxel or sirolimus) in different stent systems, PF-DES are associated with the increased risk of restenosis compared to PP-DES.

Biodegradable-Polymer Versus Polymer-Free Drug-Eluting Stents for the Treatment of Coronary Artery Disease

BACKGROUND/PURPOSE

Biodegradable-polymer (BP) and polymer-free (PF) drug eluting stents (DES) were developed to reduce the risk of delayed arterial healing observed with durable-polymer (DP) platforms. Although trials demonstrate BP-DES and PF-DES are non-inferior to DP-DES, there is limited data directly comparing these technologies. We performed a meta-analysis to assess the efficacy and safety of BP-DES versus PF-DES for the treatment of coronary artery disease.

METHODS/MATERIALS

Electronic searches were performed identifying randomized trials comparing BP-DES with PF-DES. Co-primary efficacy endpoints were target vessel revascularization (TVR), target lesion revascularization (TLR) and angiographic in-stent late lumen loss (LLL). Co-secondary safety endpoints were all-cause death, myocardial infarction (MI) and stent thrombosis (ST).

RESULTS

Of 208 studies, 5 met inclusion criteria including 1975 patients. At mean follow-up (14 ± 5 months), BP-DES were associated with significantly reduced rates of TVR (OR 0.58, 95%CI 0.37-0.92, p = 0.02), TLR (4.7% vs 9.5%) (OR 0.48, 95%CI 0.31-0.75, p = 0.001) and in-stent LLL (pooled mean difference -0.20 mm, 95%CI -0.24 to -0.16, p < 0.001). There was no difference in safety, including all-cause death (OR 1.24, 95%CI 0.68-2.28, p = 0.48), MI (OR 0.92, 95%CI 0.54-1.56, p = 0.75) or ST (OR 1.58, 95%CI 0.67-3.73, p = 0.30).

CONCLUSIONS

These data suggests that BP-DES are more efficacious when compared with PF-DES for the treatment of CAD.

Polymer-free versus durable polymer drug-eluting stents in patients with coronary artery disease: A meta-analysis

Background

Polymer-free drug-eluting stents (PF-DES) were introduced with the aim of reducing the risk of stent thrombosis associated with durable polymer drug-eluting stents (DP-DES). The comparison of safety and efficacy profiles between these two stent platforms remains unclear.

Materials and methods

We conducted electronic database searches for randomized controlled trials (RCTs) comparing patients treated with either PF-DES or DP-DES. Outcomes included definite or probable stent thrombosis (ST), myocardial infarction (MI), cardiac death, all-cause death, target lesion revascularization (TLR), and target vessel revascularization (TVR). A random-effects model was used to derive risk ratios (RRs) with 95% confidence intervals (CIs). Subgroup analyses based on different variables were also performed. After screening a total of 1026 articles, the present meta-analysis included 13 RCTs comprising 8021 patients.

Results

No significant differences were found for the risks of definite or probable ST (RR, 0.94; 95% CI, 0.62–1.43; P = 0.77), MI (RR, 1.06; 95% CI, 0.85–1.33; P = 0.61), cardiac death (RR, 0.98; 95% CI, 0.80–1.21; P = 0.88), all-cause death (RR, 0.87; 95% CI, 0.76–1.00; P = 0.06), TLR (RR, 1.12; 95% CI, 0.94–1.33; P = 0.22), and TVR (RR, 1.18; 95% CI, 0.87–1.61; P = 0.29). Similarly, no significant differences were found for all outcomes regardless of anti-proliferative drug, except for an increased risk of TLR for polymer-free paclitaxel-eluting stents compared with DP-DES (RR, 2.32, 95% CI, 1.30–4.14; P = 0.005).

Conclusions

Our findings showed that PF-DES and DP-DES confer equivalent safety and efficacy profiles, with similar rates of stent thrombosis.

•

Polymer-free and durable polymer drug-eluting stents confer similar safety and efficacy profiles.

•

There were comparable rates of stent thrombosis between the two stent platforms.

•

Further trials with greater length of follow-up are warranted to assess long-term safety and efficacy outcomes.

Efficacy and safety of polymer-free stent versus polymer-permanent drug-eluting stent in patients with acute coronary syndrome: a meta-analysis of randomized control trials

BACKGROUND

The efficacy and safety of polymer-free stent (PFS) versus permanent polymer drug-eluting stent (PPDES) in patients undergoing percutaneous coronary intervention (PCI) remain controversial. Our meta-analysis was undertaken to evaluate and compare the efficacy and safety of PFS with those of PPDES in patients undergoing PCI.

METHODS

We searched PubMed, Cochrane Library, EMBASE, and Clinical Trials.gov databases for randomized controlled trials (RCTs). The primary endpoints were incidence of stent thrombosis (ST) and target-lesion revascularization (TLR). The secondary endpoints included the incidence of major adverse cardiovascular events (MACE), myocardial infarction (MI), cardiac death (CD), late lumen loss (LLL), and diameter stenosis (DS). Subgroup analyses were also conducted based on the follow-up time.

RESULTS

Eleven RCTs met the including criteria, and 8616 patients were included in the study. No significant differences were observed between PFS and PPDES treatments in the incidence of ST (RR 0.90; 95% CI: 0.62-1.31; P = 0.58; I ²  = 0), TLR (RR 0.87; 95% CI: 0.76-1.00; P = 0.05; I ²  = 37%), CD (RR 0.89; 95% CI: 0.72-1.10; P = 0.28; I ²  = 0), MI (RR 0.87; 95% CI: 0.71-1.05; P = 0.15; I ²  = 0), LLL (SMD 0.01; 95% CI: -0.29-0.30; P = 0.96; I² = 90%), and DS (SMD -0.01; 95% CI: - 0.25 to 0.23; P = 0.93; I² = 83%). Meanwhile, the patients with PFS had a lower incidence of MACE (RR 0.87; 95% CI: 0.78-0.97; P = 0.01; I ²  = 0) than those with PPDES.

CONCLUSION

In the overall analysis, patients with PFS presented a lower risk of MACE versus PPDES, but no significant difference were obtained in the risk of ST, TLR, MI, CD, DDD and DS. In the Short term follow up, patients with PSF presented a lower risk of TLR compared with PPDES.

Rapamycin inhibits transforming growth factor beta 1 induced myofibroblast differentiation via the phosphorylated-phosphatidylinositol 3-kinase mammalian target of rapamycin signal pathways in nasal polyp-derived fibroblasts

PURPOSE

Rapamycin has antiproliferative and antifibrogenic effects in vitro and in vivo. The purpose of this study was to evaluate the effects of rapamycin on transforming growth factor (TGF) beta 1 induced myofibroblast differentiation (alpha smooth-muscle actin [SMA]), extracellular matrix production, and collagen contraction in nasal polyp-derived fibroblasts (NPDF). The underlying molecular mechanisms of rapamycin were also determined in NPDFs.

METHODS

NPDFs were grown in culture and transformed into myofibroblasts by using TGF beta 1 (5 ng/mL). For cytotoxicity evaluation, a 3-(4,5-dimethylthiazol-2yl)-2,5-diphenyl-tetrazolium bromide assay was used. Expression levels of alpha SMA, phosphorylated phosphatidylinositol 3-kinase (PI3K), and phosphorylated mammalian target of rapamycin (mTOR) were determined by using Western blot, reverse transcription-polymerase chain reaction, and immunofluorescence staining. The total amount of collagen was analyzed by using the Sircol collagen assay, and contractile activity was measured with a collagen gel contraction assay. Silencing mTOR with mTOR-specific small interference RNA was determined by using reverse transcription-polymerase chain reaction.

RESULTS

Whereas rapamycin (range, 0-400 nM) had no significant cytotoxic effects on TGF beta 1 induced NPDFs, it significantly reduced the expression levels of alpha-SMA in TGF beta 1 induced NPDFs in a dose-dependent manner. TGF beta 1 induced collagen production and collagen contraction were significantly inhibited by rapamycin treatment. Rapamycin also attenuated the TGF beta 1 induced activation of PI3K and mTOR, and its inhibitory effects were similar to those of mTOR silencing and a specific PI3K inhibitor.

CONCLUSIONS

Rapamycin inhibited TGF beta 1 induced myofibroblast differentiation, extracellular matrix production, and collagen contraction through the PI3K/mTOR signal pathways in NPDFs.

Revolution of Drug-Eluting Coronary Stents: An Analysis of Market Leaders

Percutaneous coronary intervention with drug-eluting stents (DES) is a well-established and widely-accepted treatment approach in patients with coronary artery disease. Although the underlying principle of DES remains constant for different stents available on the market, certain factors may offer variations with respect to deliverability (ease of placement), efficacy (preventing restenosis), and safety (thrombosis rates). These factors may include the type of drug (sirolimus, everolimus, biolimus, zotarolimus, novolimus, paclitaxel, docetaxel), type of stent platforms (stainless steel, platinum, cobalt-chromium, cobalt-nickel, platinum-chromium), type of polymers (permanent, biodegradable, polymer-free), thickness of stent struts (thick, thin, ultra-thin), type of coating (abluminal, conformal), and type of stent design (open-cell, closed-cell, combination of open-closed cell). In this context, we present a review on characteristic features of several of the most widely used coronary stents worldwide. Furthermore, the advancements of completely biodegradable stents are discussed. In addition, the future directions for the development of creating an ideal or perfect DES are debated.

Polymer-free versus permanent polymer drug eluting stents in coronary artery disease: A meta-analysis of 10 RCTs with 6575 patients

Background

Permanent polymer drug eluting stents (PP-DES) may induce inflammation of the vessel wall due to the existence of the polymer, which may delay intimal healing. Polymer-free DES (PF-DES) that eliminate the polymeric carrier may potentially lead to safer DES. However, the safety and efficacy of PF-DES remains controversial.

Methods

Randomized controlled trials comparing PF-DES with PP-DES were searched in online database including MEDLINE, Excerpta Medica Database (EMBASE) and Cochrane Library. Studies reporting late lumen loss (LLL), all-cause death, myocardial infarction (MI), target lesion revascularization (TLR) and late stent thrombosis (LST) were enrolled and quantitatively analyzed.

Results

Ten studies enrolling 6575 patients were included in this meta-analysis. The PF-DES showed a benefit in reducing all-cause death (OR = 0.77, 95% CI: 0.61 to 0.98, P = 0.03) and long-term LLL (weighted mean difference (WMD) −0.16 mm, 95% CI: −0.22 to −0.11 mm, P < 0.001), while no superiority was found in reducing short-term LLL (WMD 0.03 mm, 95% CI: −0.07–0.13 mm, P = 0.57), MI (OR = 1.12, 95% CI: 0.19 to 23.18, P = 0.39), TLR (OR = 1.19, 95% CI: 0.42 to 3.38, P = 0.83) and LST (OR = 0.92, 95% CI: 0.05 to 5.71, P = 0.74).

Conclusion

PF-DES showed benefits in reducing long-term LLL and mortality compared with PP-DES, but no superiority was found in short-term LLL, MI, TLR and LST. These findings provide a sound basis for the wide application of PF-DES in the future.

Comparison of the safety and efficacy of biodegradable polymer drug-eluting stents versus durable polymer drug-eluting stents: a meta-analysis

Background

A meta-analysis was conducted to assess the safety and efficacy of biodegradable polymer drug-eluting stents (BP-DESs).

Methods

PubMed, Science Direct, China National Knowledge Infrastructure, and Chongqing VIP databases were searched for randomized controlled trials comparing the safety and efficacy of BP-DESs versus durable polymer drug-eluting stents (DP-DESs). Efficacy included the prevalence of target lesion revascularization (TLR), target vessel revascularization (TVR), and late lumen loss (LLL), and safety of these stents at the end of follow-up for the selected research studies were compared.

Results

A total of 16 qualified original studies that addressed a total of 22,211 patients were included in this meta-analysis. In regard to efficacy, no statistically significant difference in TLR (odds ratio (OR) = 0.94, P = 0.30) or TVR (OR 1.01, P = 0.86) was observed between patients treated with BP-DESs and those with DP-DESs. However, there were significant differences in in-stent LLL (weighted mean difference [WMD] = −0.07, P = 0.005) and in-segment LLL (WMD = −0.03, P = 0.05) between patients treated with BP-DESs and with DP-DESs. In terms of safety, there was no significant difference in overall mortality (OR 0.97, P = 0.67), cardiac death (OR 0.99, P = 0.90), early stent thrombosis (ST) and late ST (OR 0.94, P = 0.76; OR 0.96, P = 0.73), or myocardial infarction (MI) (OR 0.99, P = 0.88) between patients treated with BP-DESs and with DP-DESs. However, there was a statistically significant difference in very late ST (OR 0.69, P = 0.007) between these two groups. In addition, the general trend of the rates of TVR and TLR of BP-DESs groups was lower than DP-DESs groups after a 1-year follow-up.

Conclusion

BP-DESs are safe, efficient, and exhibit superior performance to DP-DESs with respect to reducing the occurrence of very late ST and LLL. The general trend of the rates of TVR and TLR of BP-DESs groups was lower than DP-DESs groups after a 1-year follow-up.

Clinical performance of biodegradable versus permanent polymer drug-eluting stents: A meta-analysis of randomized clinical trials at long-term follow-up

Several types of biodegradable polymer drug-eluting stents (BPDES) have been used for percutaneous transluminal angioplasty; however, the safety and efficiency of these BPDES have not been fully evaluated. A meta-analysis was, therefore, conducted to compare the clinical performance of BPDES with that of permanent polymer drug-eluting stents (PPDES) in unselected patients with coronary stenosis. PubMed, Web of Science, Medline and The Cochrane Library were searched for randomized clinical trials (RCTs) from January 2005 to January 2014. Trials that compared BPDES with PPDES in patients with coronary stenosis were considered. Twelve RCTs with a total of 15,938 patients with coronary stenosis were included in this meta-analysis. No significant difference was found between the two arms in the incidence of major adverse cardiac events (MACE) and definite or probable stent thrombosis (DpST) at the one-year follow-up (P>0.10). The use of BPDES, however, showed a tendency towards a lower risk of MACE (P=0.09) and a beneficial effect by reducing DpST episodes (P=0.04) at long-term follow-up, particularly when compared with the incidence of DpST at the one-year follow-up. BPDES also tended to be associated with a decreased late lumen loss in patients with coronary stenosis [instrumental variable =−0.04; 95% confidence interval =−0.08–0.00; P=0.05). In conclusion, the one-year outcomes following drug-eluting stent implantation showed BPDES were noninferior to PPDES in unselected patients with coronary stenosis. Long-term clinical outcomes, however, indicated that BPDES appeared to a present a lower risk of MACE and DpST.

Stent Thrombosis with Biodegradable Polymer Drug-Eluting Stents versus Durable Polymer Sirolimus-Eluting Stents: An Update Meta-Analysis

Objective: Durable polymer sirolimus-eluting stents (DP-SES) are associated with a low risk of stent thrombosis; biodegradable polymer drug-eluting stents (BP-DES) were designed to reduce these risks. However, their benefits are still variable. Method: We undertook a meta-analysis of randomized trials identified by systematic searches of Medline, Embase, and the Cochrane Database. Results: Eleven studies (9,676 patients) with a mean follow-up of 22.6 months were included. Overall, compared with DP-SES, BP-DES significantly lowered the rate of definite or probable stent thrombosis (RR, 0.73; 95% CI, 0.55-0.97; p = 0.03; I2 = 0.0%) due to a decreased risk of very late stent thrombosis (RR, 0.26; 95% CI, 0.11-0.63; p = 0.00; I2 = 0.0%). However, BP-DES were associated with a comparable rate of early and late stent thrombosis. Meanwhile, BP-DES were associated with a broadly equivalent risk of target vessel revascularization (RR, 0.90; 95% CI, 0.78-1.03; p = 0.13; I2 = 0.0%), cardiac death (RR, 0.89; 95% CI, 0.72-1.09; p = 0.24; I2 = 0.0%), myocardial infarction (RR, 1.03; 95% CI, 0.84-1.26; p = 0.79; I2 = 0.0%), and major adverse cardiac events (MACE; RR, 0.91; 95% CI, 0.83-1.0; p = 0.08; I2 = 0.0%). Furthermore, angiographic data showed that in-stent and in-segment late luminal loss were similar between the two groups. Conclusions: Compared with DP-SES, BP-DES were associated with a lower rate of very late stent thrombosis and an equivalent risk of MACE. Larger randomized studies are needed to confirm this finding.

Stent thrombosis in patients with coronary artery disease treated with biodegradable polymer drug-eluting stents: an update meta-analysis

Delayed re-endothelialization may be the pathophysiological cause of stent thrombosis (ST). Biodegradable polymer drug-eluting stents (BP-DES) may reduce the risk of ST. The aim of this study was to evaluate the risk of ST in patients treated with BP-DES. Studies were retrieved from the PubMed, Cochrane Library, and EMBASE online databases. Twelve studies (15,155 patients) with long-term follow-up (≥ 12 months) were included. Compared with durable polymer drug-eluting stents (DP-DES), BP-DES did not significantly decrease the risk of definite and probable ST (RR, 0.89; 95% CI, 0.68 to 1.18; P = 0.425) and definite ST (RR, 0.92; 95% CI, 0.66 to 1.30; P = 0.648). Furthermore, there was no difference in the risk of late ST (RR, 1.17; 95% CI, 0.39 to 3.53; P = 0.780). However, the rate of early ST was slightly higher in the BP-DES group (RR, 1.60; 95% CI, 0.94 to 2.73; P = 0.084) than in the DP-DES group. A significant reduction in very late ST (> 12 months) was evident with the BP-DES group (RR, 0.27; 95% CI, 0.10 to 0.68; P = 0.006). Subgroup analysis showed that there was no difference in the rate of definite and probable ST between the BP-DES and first- or second-generation DES groups.Biodegradable polymer stents were associated with a significantly lower risk of very late ST. However, there was no difference in the risk of definite and probable ST between the two groups.

Clinical outcomes of biodegradable polymer drug-eluting stents for percutaneous coronary intervention: an updated meta-analysis of randomized controlled trials

Biodegradable polymer drug-eluting stents (DES) are innovative concepts in the era of percutaneous coronary intervention. We systematically reviewed the latest randomized evidence on the efficacy and safety of biodegradable polymer DES as compared to durable polymer DES. MEDLINE, Embase, and the Cochrane database were searched in August 2013 for eligible randomized controlled trials (RCTs) comparing biodegradable polymer DES with durable polymer DES. Clinical outcomes of interest were mortality, myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), and stent thrombosis. A total of 20 RCTs randomizing 20 021 participants were included, of whom 11 045 were allocated to biodegradable polymer DES and 8976 to durable polymer DES. Treatment of biodegradable polymer DES was not associated with a significant reduction of any of the clinical outcomes (all-cause mortality, odds ratio [OR]: 0.94, 95% confidence interval [CI]: 0.80 to 1.10, P = 0.42; cardiovascular mortality, OR: 0.97, 95% CI: 0.79 to 1.19, P = 0.74; MI, OR: 1.07, 95% CI: 0.91 to 1.26, P = 0.41; TLR, OR: 0.87, 95% CI: 0.69 to 1.08, P = 0.20; TVR, OR: 1.05, 95% CI: 0.85 to 1.28, P = 0.67; definite/probable stent thrombosis, OR: 0.80, 95% CI: 0.59 to 1.07, P = 0.14). Current randomized data indicate that clinical efficacy and safety profiles of biodegradable polymer DES are comparable to those of durable polymer DES. Findings from large-scale studies with rigorous methodology and long follow-up duration are needed.

Cavernous malformations of the central nervous system in the pediatric age group

OBJECTIVE

The main clinico-diagnostic features, risk factors and associated diseases of cavernous malformations (CMs), also called cavernous angiomas or cavernomas, of the central nervous system (CNS) in children are described, and the most relevant differences compared to the affected adult population are pointed out, focusing on the management of pediatric patients harboring cranial and spinal CMs.

MATERIALS

This was a retrospective study of a series of 42 children symptomatic for CMs of the cranial and spinal compartments (35 supratentorial brain lesions, 5 infratentorial and 2 in the spinal region) operated on between 1975 and 2005, with a clinical follow-up ranging from 12 to 192 months. The results were compared with those found in the most recent literature dealing with pediatric CMs of the CNS.

RESULTS

Surgical treatment produced excellent or good results in 69% of our 42 children. Unchanged neurological deficits were observed in 23.8% of cases, while morbidity from surgical procedures was 7.14%. Mortality was absent in this series. These surgical results are comparable with those found in the literature, where morbidity and mortality rates from surgery are 8.8 and 1.13%, respectively, and are mostly associated with procedures for the excision of deep, critically located cavernomas.

CONCLUSION

CMs represent the most common CNS vascular lesion in children, although their incidence is 4 times lower than that of the adult population. The natural history of pediatric CMs throughout the neuraxis seems to be more aggressive than in adult patients; these lesions have higher rates of growth and hemorrhage, larger dimensions and often atypical radiological pictures at diagnosis. Beside the familial form of the disease, which is more often associated with multiple lesions and an earlier age of clinical presentation, the major risk factor for CMs in children seems to be radiotherapy for CNS tumors. Furthermore, a greater number of CMs coexistent with mixed angiomatous lesions have been reported in children than in adults. Surgical results are related to the preoperative neurological status of the children; symptomatic patients who are operated on early, before they develop severe neurological deficits or long-standing seizures, may achieve the best clinical outcome. Radiosurgery does not seem to be advisable in children as an alternative treatment for deep CMs or those causing epilepsy.