Drug eluting stents – mechanisms of action and current indications
Authors:
S. Šimek; J. Horák; P. Kuchynka; M. Škvařilová; J. Humhal; V. Mrázek; V. Danzig; M. Aschermann
Authors‘ workplace:
Klinika kardiologie a angiologie l. LF a VFN, Praha
Published in:
Kardiol Rev Int Med 2005, 7(3): 144-150
Overview
Restenosis is after the coronary angioplasty the main limiting factor for this method of myocardial revascularization. After the implantation of coronary stents the occurrence of restenosis went down to ½. To a significant decrease of restenosis finally comes now, after the use of drug eluting stents (DES). Drug eluting stents have both – a positive mechanical action of stents on recoil and artery remodelling with a local application of drugs which inhibit neointimal hyperproliferation. This way it influences all 3 parts of the restenosis process at the same time. Currently there are available results of a 3-year-long monitoring of patients after DES implantation. During this medium-term monitoring has been proved that the implantation of drug eluting stents is safe. A low occurrence of restenosis continues during the whole time of monitoring; this results in lowered need of repeated revascularization of intervened artery in approx. 80 % of all patients’ subgroups. DES potency has been so far proved in lesion up to 46 mm; in native coronary arteries greater than 2.5 mm. Ostial lesions, calcified lesions, bifurcation lesions and lesions in bypasses have so far been excluded from randomized studies. Studies to verify drug eluting stents applicability in these indications are being conducted at present. Until now a direct proof of a favourable influence of drug eluting stents in acute coronary syndromes is missing. According to the data from registers it seems that drug eluting stents significantly decrease the occurrence of cardiac events even during acute infarction and unstable angina pectoris. Higher potency of drug eluting stents is reflected in their price, which is 2-3 times higher than the price of metallic stents. From the price efficiency point of view it is most convenient to implant drug eluting stents in patients with high risk of restenosis, where the highest absolute decrease of restenosis risk can be expected. DES use is also suitable in lesions which have an extreme importance for the patient’s prognosis, for example when treating the last transit artery or when treating the stem of the left coronary artery. This is the source for indicating criteria for implantation of DES defined by the Czech Cardiology Society. With regard to the recent increase in payments for drug eluting stents by the General Health Insurance Company and with regard to their expected price decrease, the use of drug eluting stents will surely soon spread over the Czech republic.
Key words:
DES, drug eluting stents, coronary angioplasty, restenosis
Sources
1. Lowe HC, Oesterle SN, Khachigian LM. Coronary in-stent restenosis: current status and future strategies. J Am Coll Cardiol 2002; 39(2): 183–93.
2. Grewe PH, Deneke T, Machraoui A, Barmeyer J, Muller KM. Acute and chronic tissue response to coronary stent implantation: pathologic findings in human specimen. J Am Coll Cardiol 2000; 35(1): 157–63.
3. Kornowski R, Hong MK, Tio FO, Bramwell O, Wu H, Leon MB. Instent restenosis: contributions of inflammatory responses and arterial injury to neointimal hyperplasia. J Am Coll Cardiol 1998; 31(1): 224–30.
4. Brasen JH, Kivela A, Roser K et al. Angiogenesis, vascular endothelial growth factor and platelet-derived growth factor-BB expression, iron deposition, and oxidation-specific epitopes in stented human coronary arteries. Arterioscler Thromb Vasc Biol 2001; 21(11): 1720–6.
5. Kuroda N, Kobayashi Y, Nameki M et al. Intimal hyperplasia regression from 6 to 12 months after stenting. Am J Cardiol 2002; 89(7): 869–72.
6. Aschermann M, Kovárník T, Aschermann O. Restenóza po koronární intervenci. Kapitoly z kardiologie 2000; 2: 10-12.
7. Faxon DP. Systemic drug therapy for restenosis: ‘‘deja vu all over again’’. Circulation 2002; 106(18): 2296–8.
8. Waksman R. Radiation therapy for restenosis: from preclinical studies to human trials. Stent 1997; 1: 9-13.
9. Kováč J. Použití stentů s místním uvolňováním léků (local drug delivery) v prevenci restenózy. Interv Akut Kardiol 2003; 2: 73-81.
10. Curfman GD. Sirolimus-eluting coronary stent. N Engl J Med 2002; 346: 1770-1.
11. Morice MC, Serruys PW, Sousa EJ. A randomised comparison of a sirolimus-eluting stent with standard stent for coronary revascularization. N Engl J Med 2002; 346: 1773-80.
12. Moses JW, Leon MB, Popma JJ et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 2003; 349(14): 1315–23.
13. Park SJ, Shim WH, Ho DS. A paclitaxel-eluting stent for the prevention of coronary restenosis. N Engl J Med 2003; 348: 1537-45.
14. Rowinsky EK, Donehower RC. Paclitaxel (taxol). N Engl J Med 1995; 332(15): 1004–14.
15. Grube E, Silber S, Hauptmann KE. TAXUS I: six and twelve-month results from a randomised double-blind trial on a slow-release paclitacel-eluting stent for de novo coronary lesions. Circulation 2003; 107: 38-42.
16. Colombo A, Drzewiecki J, Banning A. Randomized study to assess the effectiveness of slow - and moderate-release polymer-based paclitaxel-eluting stents for coronary artery lesions. Circulation. 2003; 108(7): 788-94.
17. Stone GW, Ellis SG, Cox DA. A polymer-based, Paclitaxel.eluting stent in patients with coronary artery disease. N Engl J Med 2004; 350: 221-231.
18. Park SJ, Shim WH, Ho DS et al. A paclitaxel-eluting stent for the prevention of coronary restenosis. N Engl J Med 2003; 348(16): 1537–45.
19. De Schreerder I. Study of antirestenosis with the BioDivYsio dexamethazone eluting stent (STRIDE). 51th Annual scientific sessions of the ACC, Atlanta, March 17-20, 2002 (přednáška).
20. Abizaid AA, New G, Abizaid AS et al. First clinical experience with 17-estradiol-eluting BiodivYsio matrix stent to prevent restenosis in de-novo native coronary arteries: sixmonth clinical outcomes and angiographic follow-up from the EASTER trial. J Am College Cardiol 2003; 41(6): 56A.
21. Cohen DJ, Bakhai A, Shi CH. Cost-effectiveness of Sirolimus-eluting stents for treatment of complex coronary stenoses, results from the SIRIUS trial. Circulation 2004; 110: 508-514.
22. Goláň L, Šimek S, Škvařilová M et al. The cost effectiveness of drug eluting stents in elective percutaneous coronary interventions. Intercath 2005.
23. Sharma S, Bhambi B. Sirolimus-eluting coronary stents. N Engl J Med 2002; 347: 1285.
24. Widímský P. Koronární bypass, revaskularizační metoda minulého století? XII. Výroční sjezd ČKS, Brno, květen 9-12, 2004 (přednáška).
25. Groch L. Jsou všechny lékové stenty stejné? XII. Výroční sjezd ČKS, Brno, květen 9-12, 2004 (přednáška).
26. De Jaegere P, Mudra H, Figulla H et al. Intravascular ultrasound-guided optimized stent deployment. Immediate and 6 months clinical and angiographic results from the Multicenter Ultrasound Stenting in Coronaries Study (MUSIC Study). Eur Heart J 1998; 19(8): 1214–23.
27. Lemos PA, Saia F, Ligthart JM et al. Coronary restenosis after sirolimus-eluting stent implantation. Morphological description and mechanistic analysis from a consecutive series of cases. Circulation 2003; 108: 257–60.
28. Babinska A, Markell MS, Salifu MO. Enhancement of human platelet aggregation and secretion induced by rapamycin. Nephrol Dial Transplant 1998; 13(12): 3153–9.
29. Finkelstein A, McClean D, Kar S et al. Local drug delivery via a coronary stent with programmable release pharmacokinetics. Circulation 2003; 107(5): 777–84.
30. Kutryk MJB, Kuliszewski MA. Progenitor cell capture for the accelerated endothelialization of endovascular devices. Am J Cardiol 2002; 90 (6A): TCT180.
31. Kereiakes DJ. Two-year SIRIUS trial follow-up. AHA meeting, Orlando, November 7-8, 2003.
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