Lack of clinical benefit of drug‐eluting compared to bare‐metal stents for treatment of transplant coronary artery disease: Why we do not need drug‐eluting stents?

Abstract

In the online version of the Journal, Lee et al. [1] reported a 5-year follow-up data from 105 patients with transplant coronary artery disease (TCAD) who underwent first vessel percutaneous coronary interventions (PCIs) either with drug-eluting stents (DESs) or bare metal stents (BMSs). Patients who were eligible for DES underwent PCI with either sirolimus-(Cypher, Cordis, Johnson & Johnson Corporation, Miami, FL) or paclitaxel-eluting stents (Taxus, Boston Scientific Corporation, Natick, MA). At our knowledge, this report was the largest follow-up available comparing these two stent strategies in TCAD patients. In this retrospective data, no difference in major adverse events was found, and furthermore, target vessel revascularization (TVR) was similar in both groups 25.5% with DES and 26.5% with BMS log rank P 5 0.76. Authors have been previously reported at short-term follow-up of a significant clinical TVR benefit with DES which was lost at 5 years. As usual in this study, all patients with TCAD were also under oral immusuppressive (OI) or antiproliferative therapy with oral sirolimus, everolimus, or prednisone.Despite the benefit of DES over BMS described in TCAD (2), the majority of these advantages were controversial: short-term outcome in most of them, nonrandomized data, and mixed results [1][2][3].Therefore, clinical value is uncertain.The nonrandomized nature of all of these studies could be one of the most attractive explanations from these findings; however, all authors [1-3] failed to mention and quoted the value of the role of OI therapy that led to similar TVR rate in many of these studies.At the present time, in no TCAD patients, shortterm oral administration of either sirolimus or prednisone after PCI with BMS implantation demonstrated in all randomized clinical studies (seven), a significant reduction in restenosis and TVR compared to BMS alone [4]. Furthermore, when compared with similar DES designs as authors used in the study [1], OI therapy showed similar clinical results to DES [5,6] which were sustained at long-term outcome [6].Finally, there is no doubt of the clinical benefit of DES over BMS alone in non-TCAD; however, that is not the case of TCAD patients undergoing PCI with stent implantation where most of them are receiving oral sirolimus, prednisone, or both. Thus, the lack of benefit of DES over BMS in TCAD should not be a surprise, although as authors stated [1], randomized studies are warranted.