Long-Term Clinical Outcomes Between Biodegradable and Durable Polymer Drug-Eluting Stents: A Nationwide Cohort Study

Comparison of Thick Biolimus A9-Eluting Stent and Thin Zotarolimus-Eluting Stent in Multi-Vessel Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES

There are limited randomized studies on patients undergoing multi-vessel percutaneous coronary intervention (PCI) comparing the outcomes between stent thickness and polymer types. To compare the clinical outcomes of thick biodegradable polymer-based biolimus A9-eluting stents (BESs) and thin durable polymer-based zotarolimus-eluting stents (ZESs) in patients undergoing multi-vessel PCI.

METHODS

A total of 936 patients who underwent multi-vessel coronary artery stenting were randomly assigned to the BES (n=472) or ZES (n=464) groups. The primary endpoint was 2-year major adverse cardiac events (MACEs), a composite of all-cause death, myocardial infarction (MI), and any revascularization at the 2-year follow-up.

RESULTS

Fifty-two (11.2%) of 472 patients in BES group and 50 (10.9%) of the 464 patients in ZES group met the 2-year primary endpoint of MACE (hazard ratio, 1.00; 90% confidence interval, 0.72, 1.38; p=0.994). All-cause death (BES vs. ZES: 2.8% vs. 2.7%, p=0.758), MI (2.1% vs. 2.6%, p=0.483), and repeat revascularization (6.7% vs. 6.9%, p=0.876) were not significantly different between the 2 groups. Although there was no significant outcome difference in any subgroup analysis, the technical failure rate leading to the use of other stents was higher in BES than in ZES (3.2% vs. 0.9%, p=0.023).

CONCLUSIONS

In patients who underwent multi-vessel PCI, BES and ZES showed comparable 2-year clinical outcomes. However, BES was not established to demonstrate non-inferiority to ZES in terms of the incidence of the primary endpoint at the 2-year. The technical success rate of the index PCI with the assigned stent was higher for thinner ZES.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01947439.

Long-term outcomes of biodegradable versus 2nd generation durable polymer drug-eluting stents in PCI: Protocol for a systematic review and meta-analysis

BACKGROUND

More than 3 million individuals globally experience STEMI each year, with percutaneous coronary intervention (PCI) as the preferred revascularization method. While second-generation Drug Eluting Stents (DES) reduce restenosis compared to bare-metal stents, complications such as neoatherosclerosis and stent thrombosis remain. Second-generation stents, including durable polymer (DP-DES) and biodegradable polymer (BP-DES), aim to improve outcomes, though guidelines do not specify a preference. Given mixed results from prior studies and new long-term data, we aim to perform a systematic review and meta-analysis comparing long-term outcomes of DP-DES vs. BP-DES following PCI.

METHODS

This protocol has been developed following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. MEDLINE, Embase, and Scopus databases will be searched for eligible observational and interventional studies from inception up to 5th of October 2024. Screening (title/abstract and full text), data extraction, risk of bias assessment, and quality of evidence assessment will be conducted by two independent reviewers. A random-effects model will be used to meta-analyse outcomes.

DISCUSSION

DES have greatly advanced PCI for STEMI. However, long-term stent thrombosis remains an issue due to chronic inflammation and impaired healing from the stent's polymer coating. To overcome this, BP-DES were introduced to dissolve their coating within 2-9 months. However, whether BP-DES offers superior long-term outcomes compared to second-generation DP-DES remains uncertain. While previous meta-analyses have shown similar outcomes, recent studies suggest BP-DES may offer better long-term results. This review will compare long-term outcomes (≥5 years) of BP-DES vs. DP-DES, providing important insights to inform clinical practice. Systematic review registration: PROSPERO (CRD42024592579).

Combination therapy with moderate-intensity atorvastatin and ezetimibe vs. high-intensity atorvastatin monotherapy in patients treated with percutaneous coronary intervention in practice: assessing RACING generalizability

AIMS

Using rosuvastatin, the RACING (randomized comparison of efficacy and safety of lipid-lowering with statin monotherapy versus statin/ezetimibe combination for high-risk cardiovascular diseases) trial showed the beneficial effects of combining moderate-intensity statin with ezetimibe compared with high-intensity statin monotherapy in patients with atherosclerotic cardiovascular disease. This study investigated whether the beneficial effects of combination lipid-lowering therapy extend to patients treated with atorvastatin, not rosuvastatin, in daily clinical practice.

METHODS AND RESULTS

Using stabilized inverse probability of treatment weighting, a total of 31 993 patients who were prescribed atorvastatin after drug-eluting stent (DES) implantation were identified from a nationwide cohort database: 6215 patients with atorvastatin 20 mg plus ezetimibe 10 mg (combination lipid-lowering therapy) and 25 778 patients with atorvastatin 40-80 mg monotherapy. The primary endpoint was the 3-year composite of cardiovascular death, myocardial infarction, coronary artery revascularization, hospitalization for heart failure treatment, or non-fatal stroke in accordance with the RACING trial design. Combination lipid-lowering therapy was associated with a lower incidence of the primary endpoint (12.9% vs. 15.1% in high-intensity atorvastatin monotherapy; hazard ratio [HR] 0.81, 95% confidence interval [CI] 0.74-0.88, P < 0.001). Compared with high-intensity atorvastatin monotherapy, combination lipid-lowering therapy was also significantly associated with lower rates of statin discontinuation (10.0% vs. 8.4%, HR 0.81, 95% CI 0.73-0.90, P < 0.001) and new-onset diabetes requiring medication (8.8% vs. 7.0%, HR 0.80, 95% CI 0.70-0.92, P = 0.002).

CONCLUSION

In clinical practice, a combined lipid-lowering approach utilizing ezetimibe and moderate-intensity atorvastatin was correlated with favourable clinical outcomes, drug compliance, and a reduced incidence of new-onset diabetes requiring medications in patients treated with DES implantation. Trial registration:  ClinicalTrial.gov (NCT04715594).

Nanotechnology in development of next generation of stent and related medical devices: Current and future aspects

Coronary stents have saved millions of lives in the last three decades by treating atherosclerosis especially, by preventing plaque protrusion and subsequent aneurysms. They attenuate the vascular SMC proliferation and promote reconstruction of the endothelial bed to ensure superior revascularization. With the evolution of modern stent types, nanotechnology has become an integral part of stent technology. Nanocoating and nanosurface fabrication on metallic and polymeric stents have improved their drug loading capacity as well as other mechanical, physico-chemical, and biological properties. Nanofeatures can mimic the natural nanofeatures of vascular tissue and control drug-delivery. This review will highlight the role of nanotechnology in addressing the challenges of coronary stents and the recent advancements in the field of related medical devices. Different generations of stents carrying nanoparticle-based formulations like liposomes, lipid-polymer hybrid NPs, polymeric micelles, and dendrimers are discussed highlighting their roles in local drug delivery and anti-restenotic properties. Drug nanoparticles like Paclitaxel embedded in metal stents are discussed as a feature of first-generation drug-eluting stents. Customized precision stents ensure safe delivery of nanoparticle-mediated genes or concerted transfer of gene, drug, and/or bioactive molecules like antibodies, gene mimics via nanofabricated stents. Nanotechnology can aid such therapies for drug delivery successfully due to its easy scale-up possibilities. However, limitations of this technology such as their potential cytotoxic effects associated with nanoparticle delivery that can trigger hypersensitivity reactions have also been discussed in this review. This article is categorized under: Implantable Materials and Surgical Technologies > Nanotechnology in Tissue Repair and Replacement Therapeutic Approaches and Drug Discovery > Nanomedicine for Cardiovascular Disease Therapeutic Approaches and Drug Discovery > Emerging Technologies.

Pathogenetic mechanisms of repeated adverse cardiovascular events development in patients with coronary heart disease: the role of chronic inflammation

Stent restenosis is the most unfavorable complication of interventional treatment for coronary heart disease. We already know from various literature sources that the causes for stent restenosis in patients are both mechanical damage (partial opening, stent breakage, extended stented area, calcification, incomplete stent coverage of atherosclerotic plaque, weak radial stiffness of the stent metal frame, lack of stent drug coating), and the neointimal hyperplasia formation which is closely related to the de novo atherosclerosis development, being a predictor of the recurrent cardiovascular event.

Long-Term Assessment of Thin-Strut BioMime Coronary Stent System in Real-World Population at Single-Center: A Retrospective Observational Study

Background

The short-term clinical outcomes of first-generation thicker-strut durable polymer-based drug-eluting stents (DES) have been widely examined. However, there is a scarcity on qualitative research on the long-term usage of DES that evaluated the thinner strut biodegradable stents for coronary artery disease. Hence, we sought to investigate the long-term safety and performance of thinner strut biodegradable polymer-based BioMime sirolimus-eluting coronary stent system in real-world patients with symptomatic ischemic heart disease.

Methods

This was a retrospective, observational, single-center, post-marketing clinical follow-up study. The primary endpoints were the incidence of major adverse cardiac events (MACE), defined as a composite of cardiac death, myocardial infarction (MI) attributed to target vessel revascularization (TVR), and target lesion revascularization (TLR) at 1-, 2-, 3- and 4-year follow-ups. The secondary endpoints were cardiac death, MI, TLR, TVR, device and procedural success rates, and stent thrombosis (ST).

Results

In all, 1,188 consecutive patients were enrolled, and 1,333 (1,257 de novo and 76 in-stent restenotic lesions) out of 1,565 lesions were treated with the study device. The mean age of patients was 53.26 ± 10.31 years and 86.2% were male. The quantitative coronary angiographic derived mean lesion length and diameter were 29.62 ± 9.62 mm and 3.01 ± 0.29 mm, respectively. The average length and diameter of the study device implanted were 30.89 ± 6.31 mm and 3.17 ± 0.25 mm, respectively. The cumulative incidence of MACE at 1-, 2-, 3-, and 4 years was 0.61%, 1.47%, 2.08%, and 3.40%, respectively, and cumulative deaths due to cardiac causes were 0.61%, 1.13%, 1.22%, and 1.83%, respectively. There were no cases of TLR or TVR at 1-year follow-up. The cumulative rate of TLR at 2-, 3-, and 4 years was 0.35%, 0.87%, and 1.57%, respectively, while that of TVR was 0.61%, 1.47%, and 2.35%, respectively. Three (0.3%) incidences of probable ST occurred during the 6-month follow-up; no new cases were reported further. In subgroup analysis, MACEs were comparable across the long- and short-length stent groups through 4-year follow-up.

Conclusions

This long-term study demonstrates the safety and performance of the ultra-thin BioMime sirolimus-eluting stent with satisfactory clinical outcomes in patients with symptomatic ischemic heart disease in real-world scenario.