Direct stenting with drug-eluting stents may be associated with better outcomes

Ron Waksman

Marco A Magalhaes (Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA) and others report in Catheterization and Cardiovascular Interventions that direct stenting with drug-eluting stent stents, overall, reduced the likelihood of major adverse cardiac events (MACE). Direct stenting was also associated with reduced rates of death/myocardial infarction.

Magalhaes et al report: “In the bare meta stent era, direct stenting was associated with better outcomes among selected patients compared with a conventional strategy of balloon predilation.” However, they note: “Although direct stenting with drug-eluting stent implantation has been increasingly adopted in clinical practice, its safety and effectiveness remain controversial”.

Speaking to Cardiovascular News, senior author Ron Waksman (Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA) said that one of the reasons why direct stenting with drug-eluting stents continues to be controversial is because, as they contain a polymer, drug-eluting stents are “considered to be less deliverable than bare metal stents and, thus, require more intense predilation”. However, he adds that there are potential benefits with direct stenting “not only from an economic perspective, because you are not using a balloon, but also in terms of outcomes. When you use predilation, you may be increasing the risk of periprocedural myocardial infarction. You can affect the side branch and possibly cause more trauma to the vessel.”

According to Waksman, data for direct stenting with drug-level stenting were lacking. Prior to this study, there have been observational, post-hoc, and few randomised studies (with Magalhaes et al noting that the two randomised studies produced conflicting evidence). Therefore, Waksman and colleagues performed a study-level meta-analysis to compare outcomes of direct stenting with those of stenting with balloon dilation in elective patients undergoing percutaneous coronary intervention.

Waksman report that they found that direct stenting, with different drug-eluting stent generations, was feasible and safe, commenting: “The difference between direct stenting and predilation was statistically significant with lower rates of MACE favouring the direct stenting approach compared to predilation. The bottom line is that we were able to replicate the results that have been demonstrated with bare metal stents.”

However, he cautions that is “a very broad statement” because the feasibility of direct stenting “often really depends on the lesion-specific characteristics”. “That is why in the concluding paragraphs of the paper in Catheterization and Cardiovascular Interventions, we are careful to say that direct stenting is only feasible for certain patients and selected lesions. We cannot say that it can be used in every patient.” In the paper, Magalhaes et al conclude: “Direct stenting with drug-eluting stents is safe and may improve outcomes in selected patients with non-complex lesions, making it the preferred approach if possible”. Furthermore, earlier in the paper, they observe that “notably” their patient population was characterised by having non-complex coronary artery disease.

Looking to the future, Waksman believes that imaging guidance—with either intravascular ultrasound or with optical coherence tomography—will be important for determining which patients may benefit from direct stenting strategy. He says: “If you use image guidance, you would be able to decide more systematically which patients definitely require predilation [because of the presence and distribution of severe calcification, proper vessel sizing etc]. There will not be so much of the guessing game there is with using angiography alone.”