Stent Thrombosis After Percutaneous Coronary Intervention: From Bare-Metal to the Last Generation of Drug-Eluting Stents

"Synergistic anticoagulant and endothelial regeneration strategy" based on mussel-inspired phospholipid copolymer coating and bioactive zeolitic imidazolate frameworks-90 to maintain the patency of CoCr stent

Given the risks of poor patient compliance and bleeding associated with current dual antiplatelet therapies, it is urgent to develop the next generation of cardiovascular stents with anticoagulation and rapid endothelialization capabilities. Inspired by the prominent bioactivity and bioavailability of zeolitic imidazolate framework-90 (ZIF-90) in driving endothelial cell (EC) morphogenesis, this research proposes a "synergistic anticoagulant and endothelial regeneration strategy" depending on mussel-inspired phospholipid copolymer (MIPC) and ZIF-90. Depending on the copolymerization of the catechol with dopamine (Dopa) monomers, Dopa/MIPC coating was immobilized on the surface of CoCr via a one-pot process for resisting the initial thrombosis induced by platelets and fibrinogen. Meanwhile, ZIF-90 was loaded on the coating via coordination effect, aiming to accelerate the proliferation and migration of ECs. Compared with CoCr, the well-designed CoCr-Dopa/MIPC@ZIF-90 not only reduced fibrinogen adhesion by approximately 40 % and platelet adhesion by almost 55 %, but also promoted the proliferation and migration of ECs significantly in vitro. Furthermore, the blood flow velocity of CoCr-Dopa/MIPC@ZIF-90 stent was similar to natural aorta and ECs coverage on it was greatly strengthened after 30 days in a rat aorta vascular stent implantation model. Collectively, CoCr-Dopa/MIPC@ZIF-90 exhibited obvious superiority in reducing the formation of thrombus and promoting endothelial regeneration, which might meet the high requirement for the next generation of vascular stent.

Influence of Previous Coronary Artery Bypass Grafting on Clinical Outcomes After Percutaneous Coronary Intervention: A Meta-Analysis of 250 684 Patients

Background

Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is the preferred strategy for treating obstructive coronary artery disease. Existing literature suggests the worsening of clinical outcomes in patients with previous coronary artery bypass grafting (CABG) history. In light of this, a comprehensive systematic review and meta-analysis was performed.

Methods

Databases including PubMed, Cochrane Library, and ScienceDirect were utilized for the inclusive systematic search dating from inception to September 01, 2023. The risk of bias assessment was performed using the Newcastle-Ottawa scale for cohort studies, and the Cochrane Risk of Bias Tool for randomized controlled trials.

Results

Ultimately, there were 16 eligible studies pooled together, involving a total of 250 684 patients, including 231 552 CABG-naïve patients, and 19 132 patients with a prior history of CABG. Overall, patients with CABG history were associated with significantly greater short-term mortality (P = .004), long-term mortality (P = .005), myocardial infarction (P < .00001), major adverse cardiovascular events (P = .0001), and procedural perforation (P < .00001). Contrastingly, CABG-naïve patients were associated with significantly greater risk of cardiac tamponade (P = .02) and repeat CABG (P = .03). No significant differences in stroke, bleeding, revascularization, or repeat PCI were observed.

Conclusion

Comparatively worsened clinical outcomes were observed, as patients with prior CABG history typically exhibit complex coronary anatomy, and have higher rates of comorbidities in comparison to their CABG-naïve counterparts. The refinement of current procedural and surgical techniques, in conjunction with continued research endeavors, are needed in order to effectively address this trend.

3D printing technology and its revolutionary role in stent implementation in cardiovascular disease

Cardiovascular disease (CVD), exemplified by coronary artery disease (CAD), is a global health concern, escalating in prevalence and burden. The etiology of CAD is intricate, involving different risk factors. CVD remains a significant cause of mortality, driving the need for innovative interventions like percutaneous coronary intervention and vascular stents. These stents aim to minimize restenosis, thrombosis, and neointimal hyperplasia while providing mechanical support. Notably, the challenges of achieving ideal stent characteristics persist. An emerging avenue to address this involves enhancing the mechanical performance of polymeric bioresorbable stents using additive manufacturing techniques And Three-dimensional (3D) printing, encompassing various manufacturing technologies, has transcended its initial concept to become a tangible reality in the medical field. The technology's evolution presents a significant opportunity for pharmaceutical and medical industries, enabling the creation of targeted drugs and swift production of medical implants. It revolutionizes medical procedures, transforming the strategies of doctors and surgeons. Patient-specific 3D-printed anatomical models are now pivotal in precision medicine and personalized treatment approaches. Despite its ongoing development, additive manufacturing in healthcare is already integrated into various medical applications, offering substantial benefits to a sector under pressure for performance and cost reduction. In this review primarily emphasizes stent technology, different types of stents, highlighting its application with some potential complications. Here we also address their benefits, potential issues, effectiveness, indications, and contraindications. In future it can potentially reduce complications and help in improving patients' outcomes. 3DP technology offers the promise to customize solutions for complex CVD conditions and help or fostering a new era of precision medicine in cardiology.

Enhanced Hemocompatibility and Cytocompatibility of Stainless Steel

The present study introduces an advanced surface modification approach combining electrochemical anodization and non-thermal plasma treatment, tailored for biomedical applications on stainless steel grade 316L (SS316L) surfaces. Nanopores with various diameters (100-300 nm) were synthesized with electrochemical anodization, and samples were further modified with non-thermal oxygen plasma. The surface properties of SS316L surfaces were examined by scanning electron microscopy, atomic force microscopy, X-ray photoemission spectroscopy, and Water contact angle measurements. It has been shown that a combination of electrochemical anodization and plasma treatment significantly alters the surface properties of SS316L and affects its interactions with blood platelets and human coronary cells. Optimal performance is attained on the anodized specimen featuring pores within the 150-300 nm diameter range, subjected to subsequent oxygen plasma treatment; the absence of platelet adhesion was observed. At the same time, the sample demonstrated good endothelialization and a reduction in smooth muscle cell adhesion compared to the untreated SS316L and the sample with smaller pores (100-150 nm). This novel surface modification strategy has significant implications for improving biocompatibility and performance of SS316L in biomedical applications.

Polymer-Drug Anti-Thrombogenic and Hemocompatible Coatings as Surface Modifications

Since the 1960s, efforts have been made to develop new technologies to eliminate the risk of thrombosis in medical devices that come into contact with blood. Preventing thrombosis resulting from the contact of a medical device, such as an implant, with blood is a challenge due to the high mortality rate of patients and the high cost of medical care. To this end, various types of biomaterials coated with polymer-drug layers are being designed to reduce their thrombogenicity and improve their hemocompatibility. This review presents the latest developments in the use of polymer-drug systems to produce anti-thrombogenic surfaces in medical devices in contact with blood, such as stents, catheters, blood pumps, heart valves, artificial lungs, blood vessels, blood oxygenators, and various types of tubing (such as for hemodialysis) as well as microfluidic devices. This paper presents research directions and potential clinical applications, emphasizing the importance of continued progress and innovation in the field.

Drug-eluting stents for coronary artery disease in the perspective of bibliometric analysis

Drug-eluting stents (DES) play a crucial role in treating coronary artery disease (CAD) by preventing restenosis. These stents are coated with drug carriers that release antiproliferative drugs within the vessel. Over the past two decades, DES have been employed in clinical practice using various materials, polymers, and drug types. Despite optimizations in their design and materials to enhance biocompatibility and antithrombotic properties, evaluating their long-term efficacy and safety necessitates improved clinical follow-up and monitoring. To delineate future research directions, this study employs a bibliometric analysis approach. We comprehensively surveyed two decades' worth of literature on DES for CAD using the Web of Science Core Collection (WOSCC). Out of 5,778 articles, we meticulously screened them based on predefined inclusion and exclusion criteria. Subsequently, we conducted an in-depth analysis encompassing annual publication trends, authorship affiliations, journal affiliations, keywords, and more. Employing tools such as Excel 2021, CiteSpace 6.2R3, VOSviewer 1.6.19, and Pajek 5.17, we harnessed bibliometric methods to derive insights from this corpus. Analysis of annual publication data indicates a recent stabilisation or even a downward trend in research output in this area. The United States emerged as the leading contributor, with Columbia University and CRF at the forefront in both publication output and citation impact. The most cited document pertained to standardized definitions for clinical endpoints in coronary stent trials. Our author analysis identifies Patrick W. Serruys as the most prolific contributor, underscoring a dynamic exchange of knowledge within the field.Moreover, the dual chart overlay illustrates a close interrelation between journals in the "Medicine," "Medical," and "Clinical" domains and those in "Health," "Nursing," and "Medicine." Frequently recurring keywords in this research landscape include DES coronary artery disease, percutaneous coronary intervention, implantation, and restenosis. This study presents a comprehensive panorama encompassing countries, research institutions, journals, keyword distributions, and contributions within the realm of DES therapy for CAD. By highlighting keywords exhibiting recent surges in frequency, we elucidate current research hotspots and frontiers, thereby furnishing novel insights to guide future researchers in this evolving field.

Effect of ticagrelor and clopidogrel dual antiplatelet therapy on MPVLR, MAADP, and AA inhibition rate in acute coronary syndrome patients after percutaneous coronary intervention

OBJECTIVE

To explore the effects of ticagrelor and clopidogrel dual antiplatelet therapy on the mean platelet volume-to-lymphocyte ratio (MPVLR), maximum amplitude of adenosine diphosphate-induced platelet-fibrin clots (MAADP), and arachidonic acid (AA) inhibition rates in patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI).

METHODS

A total of 120 patients with ACS undergoing elective PCI in our hospital between March 2020 and November 2021 were recruited. Patients were divided into 2 groups using the random number table method, with 60 patients in each group. The control group received clopidogrel + aspirin dual antiplatelet therapy, while the study group received ticagrelor + aspirin dual antiplatelet therapy. MPVLR, MAADP, and AA inhibition rates were compared between the 2 groups. Platelet activation indices, platelet micro PNA-223, and platelet gelsolin levels were measured before and 4 weeks after PCI. Changes in cardiac function indices, bleeding rates, and major adverse cardiovascular events (MACE) were compared between groups.

RESULTS

The MAADP score of the study group was lower than that of the control group 3 days after surgery (P < .05). Compared with before surgery, CD62p, CD63, miR-223, PAC-1, platelet membrane glycoprotein IIb/IIIa complex, and gelsolin levels markedly decreased in both groups 4 weeks after surgery (P < .05). The platelet activation index and platelet miR-223 and gelsolin levels were significantly lower in the study group than in the control group 4 weeks after surgery (P < .05). The overall platelet inhibition effect was significantly better in the study group than in the control group (P < .05). Compared with before surgery, the left ventricular ejection fraction and stroke volume were significantly increased, and the left ventricular end-diastolic volume and left ventricular end-diastolic diameter significantly decreased in both groups 4 weeks after surgery (P < .05). No significant differences were found between the 2 groups in terms of the incidence of bleeding events or MACE (P > .05).

CONCLUSION

Ticagrelor is more effective than clopidogrel for platelet inhibition after PCI in patients with ACS and is worthy of clinical recommendation.

Anti-inflammatory Therapy Progress in Major Adverse Cardiac Events after PCI: Chinese and Western Medicine

Acute coronary syndrome (ACS) is one of the leading causes of death in cardiovascular disease. Percutaneous coronary intervention (PCI) is an important method for the treatment of coronary heart disease (CHD), and it has greatly reduced the mortality of ACS patients since its application. However, a series of new problems may occur after PCI, such as in-stent restenosis, no-reflow phenomenon, in-stent neoatherosclerosis, late stent thrombosis, myocardial ischemia-reperfusion injury, and malignant ventricular arrhythmias, which result in the occurrence of major adverse cardiac events (MACE) that seriously reduce the postoperative benefit for patients. The inflammatory response is a key mechanism of MACE after PCI. Therefore, examining effective anti-inflammatory therapies after PCI in patients with ACS is a current research focus to reduce the incidence of MACE. The pharmacological mechanism and clinical efficacy of routine Western medicine treatment for the anti-inflammatory treatment of CHD have been verified. Many Chinese medicine (CM) preparations have been widely used in the treatment of CHD. Basic and clinical studies showed that effectiveness of the combination of CM and Western medicine treatments in reducing incidence of MACE after PCI was better than Western medicine treatment alone. The current paper reviewed the potential mechanism of the inflammatory response and occurrence of MACE after PCI in patients with ACS and the research progress of combined Chinese and Western medicine treatments in reducing incidence of MACE. The results provide a theoretical basis for further research and clinical treatment.

Zein nanospheres assisting inorganic and organic drug combination to overcome stent implantation-induced thrombosis and infection

The complication of stent implantation is the biggest obstacle to the success of its clinical application. In this study, we developed a combination way of 3D printing and the coating technique for preparation of functional polyurethane stents against stent implantation-induced thrombosis and postoperative infection. SEM, XPS, static water contact angle, and XRD demonstrated that the functional polyurethane stent had a 37 μm-thickness membrane composed of zein nanospheres (250-350 nm). Meanwhile, ZnO nanoparticles were encapsulated in zein nanospheres while heparin was adsorbed on the surface, causing 97.1 ± 6.4 % release of heparin in 120 min (first-order kinetic model) and 62.7 ± 5.6 % release of Zn²⁺ in 9 days (Korsmeyer-Peppas model). The mechanical analysis revealed that the functional polyurethane stents had about 8.61 MPa and 2.5 MPa tensile strength and bending strength, respectively. The in vitro biological analysis showed that the functional polyurethane stents had good EA.hy926 cells compatibility (97.9 ± 3.8 %), anti-coagulation response (comparable plasma protein, platelet adhesion and suppressed clotting) and sustained antibacterial activities by comparison with the bare polyurethane stent. The preliminary evaluation by rabbit ex vivo carotid artery intervention experiment demonstrated that the functional polyurethane stents could maintain blood circulation under the continuous stresses of blood flow. Meanwhile, the detailed data from the simulated implant infection experiment in vivo showed the functional polyurethane stents could effectively reduce microbial infection by 3-6 times lower and improve fibrosis and macrophage infiltration.

Drug-Eluting Stents: Technical and Clinical Progress

Drug-eluting stents (DES) demonstrated superior efficacy when compared to bare metal stents and plain-old balloon angioplasty and are nowadays used in almost all percutaneous revascularization procedures. The design of the stent platforms is constantly improving to maximize its efficacy and safety. Constant development of DES includes adoption of new materials used for scaffold production, new design types, improved overexpansion abilities, new polymers coating and, finally, improved antiproliferative agents. Especially nowadays, with the immense number of available DES platforms, it is crucial to understand how different aspects of stents impact the effect of their implantation, as subtle differences between various stent platforms could impact the most important issue-clinical outcomes. This review discusses the current status of coronary stents and the impact of stent material, strut design and coating techniques on cardiovascular outcomes.

Stent Thrombosis and Restenosis with Contemporary Drug-Eluting Stents: Predictors and Current Evidence

Iterations in stent technologies, advances in pharmacotherapy, and awareness of the implications of implantation techniques have markedly reduced the risk of stent failure, both in the form of stent thrombosis (ST) and in-stent restenosis (ISR). However, given the number of percutaneous coronary interventions (PCI) performed worldwide every year, ST and ISR, albeit occurring at a fairly low rate, represent a public health problem even with contemporary DES platforms. The understanding of mechanisms and risk factors for these two PCI complications has been of fundamental importance for the parallel evolution of stent technologies. Risk factors associated with ST and ISR are usually divided into patient-, lesion-, device- and procedure-related. A number of studies have shown how certain risk factors are related to early (1 month) versus late/very late ST (between 1 month and 1 year and >1 year, respectively). However, more research is required to conclusively show the role of time-dependence of risk factors also in the incidence of ISR (early [1 year] or late [>1 year]). A thorough risk assessment is required due to the complex etiology of ST and ISR. The most effective strategy to treat ST and ISR is still to prevent them; hence, it is crucial to identify patient-, lesion-, device- and procedure-related predictors.

Anti-atherosclerotic therapies: Milestones, challenges, and emerging innovations

Atherosclerosis is the main underlying pathology for many cardiovascular diseases (CVDs), which are the leading cause of death globally and represent a serious health crisis. Atherosclerosis is a chronic condition that can lead to myocardial infarction, ischemic cardiomyopathy, stroke, and peripheral arterial disease. Elevated plasma lipids, hypertension, and high glucose are the major risk factors for developing atherosclerotic plaques. To date, most pharmacological therapies aim to control these risk factors, but they do not target the plaque-causing cells themselves. In patients with acute coronary syndromes, surgical revascularization with percutaneous coronary intervention has greatly reduced mortality rates. However, stent thrombosis and neo-atherosclerosis have emerged as major safety concerns of drug eluting stents due to delayed re-endothelialization. This review summarizes the major milestones, strengths, and limitations of current anti-atherosclerotic therapies. It provides an overview of the recent discoveries and emerging game-changing technologies in the fields of nanomedicine, mRNA therapeutics, and gene editing that have the potential to revolutionize CVD clinical practice by steering it toward precision medicine.

Systemic Immune-Inflammation Index and C-Reactive Protein/Albumin Ratio Could Predict Acute Stent Thrombosis and High SYNTAX Score in Acute Coronary Syndrome

Acute stent thrombosis (AST) is associated with increased morbidity and mortality. The main aim of this study was to evaluate the prognostic value of the systemic immune-inflammation index (SII) and C-reactive protein (CRP) to albumin ratio (CAR) in predicting AST and high SYNTAX score in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). The criteria of the Academic Research Consortium were used to determine definite stent thrombosis. A total of 2077 consecutive patients with ACS undergoing PCI were retrospectively enrolled. Platelet, white blood cell and neutrophil counts, as well as SII, CRP, CAR, and peak cardiac troponin I (cTnI) values were significantly higher, whereas the lymphocyte count and albumin values were significantly lower in the AST (+) group compared with the AST (-) group (P < .05). SYNTAX score showed significant positive correlations with SII (r = .429, P < .001) and CRP (r = .402, P < .001). Multivariate logistic regression analysis showed that SII and CAR, as well as age, diabetes mellitus, stent length, and peak cTnI are independent predictors of AST and high SYNTAX score. In conclusion, the SII and CAR are simple, relatively cheap, and reliable inflammatory biomarkers that can predict AST and high SYNTAX scores in ACS.

Effectiveness of Direct Laser Interference Patterning and Peptide Immobilization on Endothelial Cell Migration for Cardio-Vascular Applications: An In Vitro Study

Endothelial coverage of an exposed cardiovascular stent surface leads to the occurrence of restenosis and late-stent thrombosis several months after implantation. To overcome this difficulty, modification of stent surfaces with topographical or biochemical features may be performed to increase endothelial cells’ (ECs) adhesion and/or migration. This work combines both strategies on cobalt-chromium (CoCr) alloy and studies the potential synergistic effect of linear patterned surfaces that are obtained by direct laser interference patterning (DLIP), coupled with the use of Arg-Gly-Asp (RGD) and Tyr-Ile-Gly-Ser-Arg (YIGSR) peptides. An extensive characterization of the modified surfaces was performed by using AFM, XPS, surface charge, electrochemical analysis and fluorescent methods. The biological response was studied in terms of EC adhesion, migration and proliferation assays. CoCr surfaces were successfully patterned with a periodicity of 10 µm and two different depths, D (≈79 and 762 nm). RGD and YIGSR were immobilized on the surfaces by CPTES silanization. Early EC adhesion was increased on the peptide-functionalized surfaces, especially for YIGSR compared to RGD. High-depth patterns generated 80% of ECs’ alignment within the topographical lines and enhanced EC migration. It is noteworthy that the combined use of the two strategies synergistically accelerated the ECs’ migration and proliferation, proving the potential of this strategy to enhance stent endothelialization.

Five-Year Comparative Efficacy of Everolimus-Eluting vs. Resolute Zotarolimus-Eluting Stents in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Among drug-eluting stents (DESs), the durable polymer everolimus-eluting stent (EES) and resolute zotarolimus-eluting stent (R-ZES) are widely used in clinical practice and have contributed to improve the outcomes of patients undergoing percutaneous coronary intervention (PCI). Few studies addressed their long-term comparative performance in patients with acute coronary syndrome (ACS). We aimed to investigate the 5 year comparative efficacy of EES and R-ZES in ACS. We queried ACTION-ACS, a large-scale database of ACS patients undergoing PCI. The treatment groups were analyzed using propensity score matching. The primary endpoint was a composite of mortality, myocardial infarction (MI), stroke, repeat PCI, and definite or probable stent thrombosis, which was addressed at the five-year follow-up. A total of 3497 matched patients were analyzed. Compared with R-ZES, a significant reduction in the primary endpoint at 5 years was observed in patients treated with EES (hazard ratio (HR) [95%CI] = 0.62 [0.54-0.71], p < 0.001). By landmark analysis, differences between the two devices emerged after the first year and were maintained thereafter. The individual endpoints of mortality (HR [95%CI] = 0.70 [0.58-0.84], p < 0.01), MI (HR [95%CI] = 0.55 [0.42-0.74], p < 0.001), and repeat PCI (HR [95%CI] = 0.65 [0.53-0.73], p < 0.001) were all significantly lower in the EES-treated patients. Stroke risk did not differ between EES and R-ZES. In ACS, a greater long-term clinical efficacy with EES vs. R-ZES was observed. This difference became significant after the first year of the ACS episode and persisted thereafter.

Vascular Wall Reactions to Coronary Stents-Clinical Implications for Stent Failure

Coronary stents belong to the most commonly implanted devices worldwide. A number of different types of stent exist, with very different mechanical and biochemical characteristics that influence their interactions with vascular tissues. Inappropriate inflammatory reactions are the major cause of the two major complications that follow implantation of stents in a percentage as high as 5-20%. It is therefore important to understand these reactions and how different they are among different generations of stents.