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Stent Thrombosis With Drug-Eluting Stents and Bioresorbable Scaffolds: Evidence From a Network Meta-Analysis of 147 Trials

Selected in JACC Cardiovascular Interventions by S. Brugaletta

References

Authors

Kang SH, Chae IH, Park JJ, Lee HS, Kang DY, Hwang SS, Youn TJ, Kim HS

Reference

JACC Cardiovasc Interv. 2016 Jun 27;9(12):1203-12

Published

June 2016

Link

Read the abstract

My Comment

What is known

Drug-eluting stents (DES) have become an essential component in the treatment of coronary artery disease, with a reduction of repeat revascularization compared with bare-metal stents (BMS). However, concerns about the long-term safety of earlier generation DES have provoked recent advances in DES: thin-strutted devices have replaced previous thick-strutted ones. Because studies suggested that polymer may trigger local inflammation and, subsequently, late stent thrombosis, there has been diversification in polymer choice and coating technology, including durable but biocompatible polymers, biodegradable polymers (BP), and even polymer-free devices. The latest development was the introduction of bioresorbable vascular scaffolds (BVS), which provide transient mechanical support and antirestenotic drug delivery followed by complete resorption for years.

This study compared the safety of various contemporary DES including BVS in terms of the risk of stent thrombosis (ST) or device thrombosis. 

Major findings 

  • A total of 147 trials including 126,526 patients were analyzed in this study.
  • All contemporary DES were superior to BMS and PES (paclitaxel-eluting stent) in terms of definite or probable stent thrombosis at 1 year.
  • CoCr-EES (everolimus-eluting stent), PtCr-EES, and H-SES (hybrid sirolimus-eluting stent) were associated with significantly lower risk than BVS.
  • CoCr-EES and H-SES were superior to SES and BP-BES (Biolimus eluting stent).
  • The risk of myocardial infarction was significantly lower with H-SES than with BVS.
  • There were no significant differences regarding all-cause or cardiac mortality.
  • Contemporary devices including BVS showed comparably low risks of repeat revascularization. 

My comment

This study represents the most comprehensive and updated network meta-analysis comparing contemporary coronary stents and scaffolds. The results shown are not against those coming from the analysed trials. The additional value of the present analysis is that using the methodology of the network meta-analysis allows comparison of devices not directly compared in a trial. The take home messages are that second-generation DES, in particular PtCr-EES, H- SES, and CoCr-EES, are associated with low risk of ST, as compared to BMS and first-generation DES. The overall risk of repeat revascularization with contemporary devices, including BVS, is low. The risk of BVS thrombosis was higher than second-generation DES. It was interesting that despite a higher risk of thrombosis, BVS does not exhibit a higher risk of repeat revascularization.

Given inherent limitations of network metanalysis, some caution should be taken in interpreting the study results, as BP-EES, H-SES, dual DES, and BVS had limited numbers of comparisons and limited length of follow-up, and some of the studies had a potential risk of bias. 

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