Drug-eluting stents: effective and safe for every patient and every lesion?

When Andreas Grüntzig performed the first percutaneous transluminal coronary angioplasty in 1978, he did not expect that this procedure would become one of the most often performed interventions in medicine worldwide. The Achilles’ heels of balloon angioplasty were early reocclusions and restenosis. However, .60% of the patients after plain old balloon angioplasty did well without any need for repeat target lesion revascularizations. With the introduction of stents, the procedure became more predictable with respect to early reocclusions and the rate of clinically driven repeat revascularization procedures declined to 20%, depending on lesion characteristics such as vessel diameter and lesion length and concomitant diseases such as diabetes mellitus and renal insufficiency. However, in randomized clinical trials, no benefit in death and re-infarction was observed with stenting, compared with balloon angioplasty alone. Despite this fact, currently, 80–90% of the percutaneous coronary interventions (PCIs) are performed with a stent. Soon it became clear that even stents were associated with considerable restenosis rates in some subgroups, namely, diabetics, bifurcation lesions, in-stent restenosis, and long lesions in small vessels.