Nitric-oxide coated bioactive titanium stents: safer and more effective than second-generation drug-eluting stents?

Polymer-coated drug-eluting stents (DESs) have become the treatment of choice in most patients undergoing percutaneous coronary interventions. Although these stents are effective in the sense that they reduce the restenosis rate and the need for repeat intervention by 70% compared with bare-metal stents, concerns have been raised about a series of risks closely related to the metal mesh of the stent and the polymer coating. Thus, in recent years, interest has been renewed in alternative strategies and technologies to promote repair mechanisms after stent implantation. In general, a DES consists of a platform (made from different alloys) that acts as a scaffold for the vessel, a polymer coating (hardwearing and bioabsorbable) that includes certain copolymers to confer the desired degree of thromboresistance and hemocompatibility on the stent, and the drug which is released to provide the antiproliferative properties of the device. Guided by the above general considerations, a nitric-oxide coated bioactive stent (NO-BAS, Titan-2, Hexacath; Paris, France) was developed. Although not a DES, NO-BASs have been presented as a safe and feasible alternative to bare-metal stents. Articles by López-Mı́nguez et al and Tuomainen et al published in Revista Española de Cardiologı́a describe the results of 3 studies and a meta-analysis that assessed the efficacy and safety of NO-BASs compared with DESs in 2 different clinical settings: acute coronary syndrome with ST-segment elevation (STEACS) (TITAX-AMI and BASE-ACS) and diabetes mellitus (TITANIC XV). Tuomainen et al report a pooled analysis of patients with STEACS from the TITAX-AMI and BASE-ACS studies. Specifically, in the TITAX-AMI study, the safety and efficacy of NOBASs were compared with those of first-generation paclitaxel DESs (TAXUS Liberte, Boston Scientific; Natick, Massachusetts, United States). In the BASE–ACS and TITANIC XV trials, in contrast, NOBASs were compared with second-generation DESs comprising a cobalt-chromium scaffold that elutes everolimus from the coating (XIENCE V, Abbott Vascular; Santa Clara, California, United States). In general, the 3 studies confirm the safety of NO-BASs. Rates of