The Choice Of Optimal Coronary Stents: Is It Possible To Maximize Cost-Effectiveness?

Percutaneous Coronary Interventions (PCI) has become standard-of-care management of obstructive Coronary Artery Disease (CAD), Particularly in Acute Coronary Syndromes (ACS). Only balloon dilation i.e., plain old balloon angioplasty (POBA) despite reducing coronary stenosis and improving symptoms, had unacceptable restenosis rates and at times catastrophic abrupt vessel closure. A bare-metal Stent (BMS) was invented to overcome such issues. The improved results with BMS were sensational as it reduced catastrophic abrupt vessel closure and restenosis significantly [1]. However with increasing experience, the enthusiasm with BMS gradually faded, as more and more patients with restenosis (though less than that with POBA) were encountered. As neointimal proliferation was the main culprit for stent restenosis, cytotoxic drugs (paclitaxel and sirolimus)eluting stents were developed in an attempt to further reduce restenosis rates. However, all the technology-related innovations had their limitations, like the need for longer duration of dual antiplatelet drugs for 1-year and greater cost thus leading to unaffordability in most countries. With the epidemic of CAD particularly in developing world coupled with the higher cost of DES (3 to 5 folds higher than BMS), many health insurancesystems or government-sponsored health-care systems became overstretched. There is impending need to address this issue, if we wish to preserve and further the art and science of coronary stenting.