Coronary Stenting
Ramish Riaz
Stents
• Stents are metallic scaffolds that are deployed within
a diseased segment of coronary artery to establish
and then maintain a widely patent lumen.
• despite progressive improvement in the results of
conventional balloon angioplasty, it remains limited
by abrupt vessel closure (which leads to emergency
bypass surgery in 1% of patients) and restenosis
(which prompts a repeat revascularization procedure
in 30% of patients). The attraction of stenting is that
it addresses both of these shortcomings.
Stent Designs
• More than 30 stent types have been implanted in the human coronary circulation
• Stent types differ in their composition (e.g., stainless steel, tantalum, nitinol),
architecture (e.g., slotted tube, coiled wire), and mode of implantation (e.g., self-
expanding, balloon-expandable) .
• In theory, the perfect coronary stent would be made of a relatively
nonthrombogenic material and have sufficient flexibility in its unexpanded state to
allow passage through guiding catheters and tortuous vessels. Despite its flexibility
and low profile in the collapsed state, it should have an expanded configuration that
provides uniform scaffolding of the vessel wall with low recoil and maximal radial
strength. In addition, the stent should be sufficiently radioopaque to allow
fluoroscopic visualization but not so opaque as to obscure important vascular
details.
• All clinically tested coronary stents have been constructed from metallic alloys,
including stainless steel, tantalum, nitinol, and cobalt/platinum. The largest
experience has been with stainless steel. Although each stent design is unique, they
can be divided into broad categories based on whether they are balloon-expandable
or self-expanding, and subcategorized based on architecture (e.g., coil, tube, hybrid
tube-coil).
Balloon-Expandable Stents
• Balloon-expandable stents are delivered into the
coronary artery in their collapsed state, mounted on
a delivery balloon.
• Once in the desired location, inflation of the delivery
balloon expands the stent and imbeds it into the
arterial wall.
• Within the balloon-expandable stent category, all
stents can be assigned to one of three subgroups,
based on construction: wire coils, slotted tubes, and
modular designs.
Wire Coils
• The Gianturco-Roubin FlexStent was the initial coil stent
prototype.
• It was constructed by winding stainless steel wire into a
serpiginous pattern of reversing loops and then folding that
pattern onto a compliant balloon to create an interdigitating
coil.
• Although this device was the first stent to receive FDA
approval (in 1993), its mechanical deficiencies (e.g., low axial
and radial strength and a tendency for plaque to prolapse
through large gaps between adjacent loops) largely limited its
use to acute or threatened vessel closure.
• To address these deficiencies, a second-generation Gianturco-
Roubin II (GR-II) stent incorporated a longitudinal spine to
enhance radial and axial strength. For ease of manufacture,
the desired geometry was actually cut from a flat sheet, and
small dots of gold solder were placed at each end of the stent
to enhance radiographic visualization. Although this design
retained the excellent flexibility and deliverability of the
original, the GR-II was still troubled by plaque prolapse and
excessive recoil
Slotted Tubes
• Palmaz introduced the concept of an endovascular prosthesis
whose wall was made of offset rows of rectangular slots,
each of which was plastically deformed into a “diamond”
during expansion. In their expanded state, these diamonds
(like the trusses of a bridge) made the stent relatively
resistant to recoil and compression. however, were relatively
rigid and difficult to deliver through angulated guiding
catheters or tortuous vasculature.
• Schatz therefore modified the original Palmaz design by
breaking the 15-mm rigid length, However the Palmaz-Schatz
stent proved susceptible to being stripped off the balloon,
leading to systemic embolization if the target lesion could
not be crossed.
• In an effort to preserve the radial strength and wall coverage
of the tubular design but improve flexibility in the collapsed
state, a number of newer (second- and third-generation)
slotted-tube stents were developed. These included the
modified Palmaz-Schatz geometry of the Crown (Cordis), the
MultiLink and Duet (Guidant Corporation, Santa Clara, CA),
and the NIR (Medinol, Israel) stent.
Modular Stents
• Despite enhanced flexibility, even second-
generation slotted-tube stents are sometimes
difficult to deliver through tortuous and
noncompliant vessels. In an effort to enhance
flexibility and deliverability without sacrificing
the excellent scaffolding of the slotted-tube
stents, the modular or hybrid stents are
constructed by flexibly joining multiple, short
repeating modules to each other.
• The initial modular stent was the MicroStent
was extremely deliverable but limited by low
surface coverage and radial strength.
Subsequent designs incorporated an
elliptorectangular strut profile and reduced
the length of the individual modules to 3 mm
(Micro II), 2 mm (GFX), and 1.5 mm (S670),
with further reductions in crossing profile and
increased surface area coverage.
Self-Expanding Stents
• The prototype self-expanding stent—the Wallstent (Boston
Scientific, Minneapolis, MN)—is a direct descendent of the first
coronary stent used in 1985. It is manufactured from 16
stainless steel wire strands that are woven together to form a
mesh tube .
• The stent is positioned on the delivery system in its collapsed
state, constrained by an outer membrane. Retraction of the
membrane allows the stent to reassume its unconstrained
(expanded) geometry, which can be reinforced by balloon
dilatation within the stent, if necessary.
• Self-expanding stents typically are selected to have an
unconstrained diameter that is oversized by 0.50 to 1.0 mm
• This ensures contact with the vessel wall
• Although self-expanding stents are extremely flexible and can
be delivered through tortuous vessels without risk of
dislodgement, the difficulties relating to accurate sizing and
precise placement necessitate a longer operator “learning
curve” and render these stents unsuitable for the treatment of
Indications for Stenting
• Acute or Threatened Closure: Balloon expansion within an arterial stenosis causes luminal
enlargement by overall vessel expansion and fracture of atheromatous plaque, but the
combination of medial dissection and elastic recoil causes sufficient luminal compromise to
culminate in abrupt vessel closure in roughly 5% of lesions treated by balloon angioplasty.
One of the major benefits of stenting is the ability to definitively reverse abrupt closure due
to dissection and recoil, and thus eliminate the need for high-risk emergency bypass surgery.
• Elective Stenting of Focal, De Novo Native Coronary Lesions
• Saphenous Vein Graft Lesions
• Restenosis After Previous Angioplasty
• Chronic Total Occlusions
• Acute Myocardial Infarction
• Long Lesions
• Small Vessels
• Aortoostial Lesions
• Bifurcation Lesions
• Intramyocardial Bridging and Refractory Coronary Vasospasm
• Multivessel Stenting
Complications
• Thrombotic and Hemorrhagic Complications: Surface charge, surface texture,
and surface energy all contribute to the thrombogenic potential of metallic
endovascular prostheses
• In-stent Restenosis: stenting reduces restenosis compared with conventional
angioplasty alone, the exponential growth in stent usage has led to new
challenges in the treatment of in-stent restenosis. Restenosis after stent
placement is caused almost exclusively by smooth muscle hyperplasia ,
superimposed on a small amount of initial recoil. number of agents—including
heparin, angiopeptin, angiotensin-converting enzyme inhibitors, and
antioxidants—have shown promise in reducing the exuberant proliferative
response evoked by stenting
• Side Branch Occlusion: In the early experience with the Palmaz-Schatz stent,
Fischman et al. (126) and Iniguez et al. (127) reported a 5% incidence of acute
branch occlusion when the stent was placed across a major (more than 1 mm)
side branch. In all such cases, ostial stenoses greater than 50% had been
present in the involved side branch. Because stenting may induce vasospasm in
the involved side branch, administration of intracoronary nitroglycerin alone is
sometimes adequate to restore normal flow.
Complications
• Stent Embolization :In the initial multicenter registry, in which the Palmaz-Schatz coronary
stent was hand-mounted on a conventional angioplasty balloon and no sheath was used, stent
embolization occurred in 2.5% of patients. Sheathed delivery systems, such as the Palmaz-
Schatz Stent Delivery System (Cordis) or the Sheathed MultiLink System (Guidant), reduce the
chance of embolization.
• Incomplete stent expansion : may result from rupture of the delivery balloon or failure of the
balloon to be expanded adequately in calcified or fibrotic vessels. If the stent is markedly
under expanded at the end of the procedure, the administration of a platelet glycoprotein
IIb/IIIa receptor antagonist may reduce the risk of stent thrombosis.
• Perforation :Although the routine use of high-pressure postplacement dilatation improves
stent expansion, the significant barotrauma imparted to the vessel may result in frank
perforation.
• Infectious Endarteritis: Placement of a foreign body endovascular prosthesis carries a
theoretic risk of bacterial endarteritis. In the early stenting experience, all patients received 48
hours of antibiotic prophylaxis during and after stent placement.
• Cost: In the present era of cost-consciousness, new technologies that affect not only clinical
outcome but also resource utilization have come under intense scrutiny. There is no better
example than coronary stenting, where the cost of a single stent (approximately $1,200) may
exceed that of an angioplasty balloon by a factor of 4.
Future Technology
• Coated Stents
• Metallic stents are inherently thrombogenic and also provoke an
exuberant hyperplastic response within the first year after deployment.
Given these limitations, modifications to the metallic surface to reduce
its thrombogenicity and alter the long-term arterial response to injury
would be desirable. Most stent coatings are polymers, which can be
divided into biodegradable and nonbiodegradable groups).
Biodegradable polymers such as polyurethane, polyethylene
terephtalate, and polyorganophosphazene were investigated but were
found to provoke intense inflammatory reactions. An example of a
nonbiodegradable coating that has been used clinically is Biogold, a 30-
nm-thick hydrocarbon layer applied by gas exchange to the Wallstent.
Other nonbiodegradable coatings that are presently under investigation
include phosphorylcholine ,amorphous hydrogenated silicon carbide
diamond-like carbon, and pyrolitic carbon.
Drug-eluting Stents
• In the future, stent coatings may also serve as reservoirs for the local delivery of
active antiplatelet, antithrombotic, and antiproliferative agents. The largest
experience to date with a coated stent has been with the heparin-coated Palmaz-
Schatz coronary stent, in which heparin molecules are covalently bound by end-
point attachment to a polymerized surface. The stent does not elute heparin, but it
allows heparin to function as an “ in situ” catalyst for activation of antithrombin III.
Low rates of thrombosis have been observed in the four large studies using this
device.
• The other approach is to use biodegradable polymers to slowly release
pharmacologically active agents. Animal studies have demonstrated that drugs such
as forskolin (142) and dexamethasone (143), when embedded into a polymer
matrix, can be incorporated into the arterial wall at concentrations several orders of
magnitude higher than serum levels. Although the notion of a “therapeutic stent” is
attractive, significant hurdles remain, such as identifying appropriate therapeutic
agents and noninflammatory polymers, as well as defining optimal delivery kinetics
and dosage. Finally, stents may be seeded with cells that secrete biologically active
proteins
Radioactive Stents
• Fischell and colleagues ( 145) showed that stent
wires impregnated with a b emitter (phosphorus
32) inhibited subsequent growth and migration of
cultured smooth muscle cells. The concept of a
radioactive stent offers several theoretic advantages
over other methods of endovascular brachytherapy,
but clinical trials with the 32P b-emitting Isostent, in
which a Palmaz-Schatz coronary stent is
impregnated with 90Sr (half-life, 14 days) (Cordis),
have shown mixed results.
Covered Stents
• The difficulty in coating stents with noninflammatory polymers has led to the
investigation of stents covered completely by artificial or natural material.
Stefanidis described a technique for sewing thin segments of autologous
veins or arteries to a metallic stent ( 148). The initial clinical experience with
these autologous stents in thrombus-containing lesions and degenerated
saphenous vein grafts has been encouraging, but the long-term outcome
compared with uncovered stents has not been studied prospectively.
• A more practical approach has been the use of stents covered by synthetic
material. The Jostent (Jomed) Coronary Stent Graft is layer of
polytetrafluoroethylene (PTFE) “sandwiched” between two layers of slotted-
tube stent ( Fig. 25.11). This covered stent has a relatively low crimped profile
and may be an ideal choice for sealing perforations, excluding coronary
aneurysms, and decreasing distal embolization when stents are placed in
friable lesions. Although initial clinical results suggest that the PTFE-covered
portions of the stent are largely free of hyperplasia, pharmacologic regimens
to prevent thrombosis and avoidance of restenosis at the uncovered edges
are ongoing issues
CONCLUSIONS
• More than 30 years after Charles Dotter first proposed the concept
of an endovascular prosthesis, coronary stenting has emerged as the
dominant technology for catheter-based coronary revascularization.
• The availability of stents with excellent deliverability and
scaffolding, the demonstration that stenting improves acute and
long-term outcome in a wide variety of lesion types, and the
development of effective and better-tolerated regimens to prevent
stent thrombosis have facilitated the application of stenting to
almost every lesion subset. In the future, stents also have the
potential to provide regional arterial delivery of bioactive drugs or
radiation to help prevent both thrombosis and subsequent
restenosis.
