A Chicken in Every Pot and a Drug-Eluting Stent in Every Lesion

Abstract

A 78-year-old man is admitted with episodes of severe angina associated with hypotension. Urgent angiography finds critical left main stenosis with wellpreserved left ventricular function (Figure 1). While discussing the treatment plan with the physician, the patient suddenly manifests sustained ventricular fibrillation. Prompt electrocardioversion restores sinus rhythm, but there is electromechanical dissociation and no blood pressure. Chest compressions are initiated. A guiding catheter quickly inserted into the left coronary finds total occlusion of the left main ( Figure 2). Between chest compressions, the left main is opened with balloon angioplasty (Figure 3), and a stent is implanted, restoring flow, contractility, and blood pressure. The patient is discharged 3 days later, sustaining only a small rise in cardiac enzymes. See p 1942 and p 1948Is this case unusual? Some might argue "no." Stents and balloon angioplasty have been used for decades to rescue patients from disaster. However, in one way, this 78-year-old man underwent a revolutionary procedure. This patient's left main coronary artery was treated with a drug-eluting stent (DES). Three months later, a follow-up angiogram found no evidence of restenosis ( Figure 4). If further follow-up of this and other patients enrolled in left main DES trials prove favorable, the paradigm could shift, making DES the treatment of choice for obstructive left main coronary disease.In the present issue of Circulation, the results of 2 pivotal trials testing paclitaxel-eluting stents are presented. One underscores the important clinical benefits of DES, whereas the other provides insights into how this exceptional new technology can be improved. Stone et al 1 present the 1-year results of the TAXUS IV randomized trial, which conclusively demonstrates the superiority of a polymer-based paclitaxel-eluting stent over a bare-metal stent. In this large, double-blind, randomized trial, the TAXUS stent (Boston Scientific) reduced ischemia-driven target-lesion revascularization at 1-year follow-up by 73% (from 15.1% to 4.4%; PϽ0.0001). TAXUS IV stands alongside the SIRIUS trial 2 (which tested a polymer-based sirolimus-eluting stent) to provide a solid foundation of evidence supporting the nearexclusive use of DES. With 2 conclusive trials, the arguments against DES become increasingly awkward to justify. These arguments are almost always motivated by economic rather than clinical concerns. Indeed, DES is an extraordinarily expensive therapy. However, our patients' needs must come first. In my opinion, unless it is unavailable or undeliverable or the patient has a clinical contraindication (usually to prolonged antiplatelet therapy), a DES should be implanted. Implications for Your Clinical PracticeIn light of the dramatically improved outcomes demonstrated in recent DES trials, physicians will need to rethink how they manage patients with obstructive coronary artery disease. At 1 year in TAXUS IV and SIRIUS, the need for revascularization of the target lesion in the DES a...

Neointima Inhibition: Comparison of Effectiveness of Non–Stent-based Local Drug Delivery and a Drug-eluting Stent in Porcine Coronary Arteries

“…In coronary arteries, restenosis inhibition by drug-eluting stents is safe and efficacious (3). Nevertheless, in some procedures, such as treatment of instent restenosis or stenoses in bifurcations, stents are either not desirable or not applicable (23). A clinical trial of coronary in-stent restenosis has shown effectiveness of paclitaxel-coated balloons (24).…”

Do Pharmacokinetics Explain Persistent Restenosis Inhibition by a Single Dose of Paclitaxel?

“…Animal experiments 1,2 and clinical trials 3 indicated that sustained release and the choice of a suitable drug were mandatory for effective inhibition of restenosis during the months and years after angioplasty. 4,5 It is surprising that a single immediately released dose of a drug requiring sustained release when coated on a stent inhibits neointimal proliferation in animals for weeks and restenosis in patients for years. 6 Paclitaxel concentrations in the vessel wall shortly after treatment with the dissolved drug or drug-coated balloons have been reported [7][8][9][10][11][12][13] but little is known about the residence time of the drug, which may be relevant for the persistent effect if administered only during the short time of balloon inflation.…”

The life and hard times of a coronary surgeon

“…This prompted a 'PCI frenzy' and 'DES euphoria', with calls to "put surgeons out of business" (1). Cardiac surgeons went from denial to despair and, in many instances, panic.…”