Stent length and outcomes after drug-eluting stent placement: time to redefine long lesions

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Percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) is an established treatment for patients with obstructive coronary artery disease 1,2. The number of PCI procedures performed annually worldwide is estimated to reach millions. DES technology has advanced significantly over the past decade, and very late stent thrombosis might be less of a clinical issue with the use of newer-generation DESs. The newer-generation DESs have thinner metal struts and biocompatible durable polymers, which potentially improve patient outcomes. In fact, the superiority of the newer-generation DESs over the first-generation DESs has been shown with a reduced risk of very late stent thrombosis 3,4. Nevertheless, the presence of a nondegradable polymer in the coronary arteries after drug release has been a theoretical concern because it can cause prolonged inflammatory responses and delay healing of vascular endothelium with a potential risk of very late stent thrombosis. The biodegradable-polymer DESs were introduced to overcome these issues with the anticipation of reducing the risk of late stent thrombosis. This polymer will completely degrade into harmless compounds after drug release, leaving behind a bare metal stent (BMS). A number of studies have been published to compare two different types of newer-generation DESs, showing that DESs coated with a biodegradable polymer are largely similar to DESs coated with a durable polymer in terms of target lesion failure 5–7. In this issue of the Journal, the investigators reported the efficacy and safety of Nobori biolimus-eluting stent (Terumo, Tokyo, Japan) with a biodegradable polymer in an all-comer population who underwent PCI 8. At 1 year, the rate of major adverse cardiac events was 3.5% and the incidence of definite and probable stent thrombosis was 0.5%. These findings support that biodegradable polymer DESs are safe and efficacious alternatives to currently used durable polymer DESs.
Long lesions have been defined as lesions of more than 20 mm in length, which significantly increased the risk of acute procedural complications and late restenosis after conventional balloon angioplasty 9,10. The use of BMSs significantly reduced the incidence of acute procedural complications and restenosis after PCI. However, stent length was strongly linked to the incidences of stent thrombosis and restenosis 11,12. Most studies reported an ~50% rate of restenosis in long lesions of more than 20 mm because of pronounced neointimal hyperplasia 11,12. The high restenosis rate was observed with multiple overlapping BMSs and single long BMSs, making stenting difficult as a primary therapeutic option for diffuse coronary artery disease. Although advances in device technology, implantation techniques, and antiplatelet therapy enabled long BMS implantation, the full coverage of long lesions with long BMSs is controversial. Therefore, long BMSs were mainly used to treat acute complications after PCI, such as long dissection.
The availability of DESs has a major influence on the patterns of revascularization for the treatment of obstructive coronary artery disease. The applicability of PCI continues to expand to more complex lesions such as long coronary lesions. Full lesion coverage with DESs is considered the preferred approach to minimize the risk of stent edge restenosis and the stented length is inevitably increased in the era of DESs. Early DES studies have shown that the risk of target lesion revascularization was significantly associated with total stent length 13. However, Choi et al. 14 reported that stent lengths of more than 32 mm was associated with poor clinical outcomes in patients with first-generation DESs, but not in those with newer-generation DESs. Bouras et al.15 also showed that in patients who received an everolimus-eluting stent, clinical outcomes at 1 year were not significantly different between those with very long lesions (>35 mm) and those with long lesions (>24 to <35 mm).

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