What is the most suitable stent design for a patient requiring stent placement, considering individual patient characteristics and clinical scenario, including demographics, medical history, and coronary anatomy?

Stent Selection Strategy Based on Clinical Context

Drug-eluting stents (DES) should be the default choice for nearly all coronary lesions, with specific second-generation DES types selected based on lesion characteristics, patient comorbidities, and procedural complexity. 1

Primary Decision Framework

Step 1: Assess Dual Antiplatelet Therapy (DAPT) Tolerance

• Can the patient tolerate and comply with 12 months of DAPT? This is the critical first decision point. 2, 1
• If YES: Proceed with DES selection algorithm below 1
• If NO: Consider bare-metal stent (BMS) or balloon angioplasty with provisional stenting, particularly if invasive/surgical procedures requiring DAPT interruption are anticipated within 12 months 2
• High bleeding risk patients: Polymer-free biolimus-eluting stents may be considered 3

Step 2: Match Stent Type to Lesion and Patient Characteristics

Small Vessel Disease (<2.5mm diameter)

• Sirolimus-eluting stents (SES) are preferred 1, 3
• DES strongly recommended over BMS due to superior outcomes in small vessels 1

Bifurcation Lesions

• Everolimus-eluting stents (EES) or zotarolimus-eluting stents are preferred 1, 3
• Bifurcation-dedicated stent designs may improve branch accessibility in complex morphologies 4

Chronic Total Occlusions (CTO)

• Everolimus-eluting stents are preferred 3
• Specialized CTO wires and devices may be required for lesion crossing 2

Long Lesions and Multivessel Disease

• Biodegradable-polymer sirolimus-eluting stents for multivessel PCI 3
• DES strongly preferred over BMS for long lesions 1

Left Main Disease

• DES strongly preferred over BMS 1
• IVUS guidance should be used to optimize stent sizing and deployment 2

Saphenous Vein Grafts

• DES preferred over BMS 1
• Consider distal protection devices during intervention 2

Diabetic Patients

• SES, EES, or polymer-free stents are recommended 3
• DES strongly preferred due to higher restenosis risk in diabetics 1

Acute Coronary Syndrome

• Ultrathin biodegradable-polymer DES or titanium-nitride-oxide-coated stents 3
• Second-generation DES provide superior outcomes with target lesion failure rates of 4.2% vs 6.8% for first-generation 1

In-Stent Restenosis

• Drug-eluting balloons (DEB) are the preferred treatment, particularly after prior BMS implantation 1
• DEB reasonable when additional stent layers are undesirable 1

Step 3: Technical Considerations

Deliverability Assessment

• DES may be more difficult to implant than BMS due to polymer coating that stiffens the stent and reduces conformability 2, 1
• Consider BMS if DES cannot be successfully implanted due to severe calcification, tortuosity, or complex anatomy 2
• Newer cobalt chromium alloy platforms have lowered crossing profiles by thinning struts 4

Lesion Preparation

• Severe calcification: Use atherectomy devices (rotational, orbital, laser), intravascular lithotripsy, or cutting balloons before stent deployment 2
• Intravascular imaging (IVUS or OCT) should be used to optimize stent sizing, assess lesion characteristics, and confirm adequate deployment 2
• IVUS guidance reduces target vessel failure (2.9% vs 5.4%), target lesion revascularization, and stent thrombosis compared to angiography alone 2

Safety Profile and Long-Term Outcomes

Stent Thrombosis Risk

• Greatest risk occurs within first year (0.7-2.0%), with late stent thrombosis rates of only 0.2-0.4% per year thereafter 1
• Second-generation DES have superior safety profiles compared to first-generation devices 1
• Extended DAPT (12 months minimum) is mandatory after DES implantation 2, 1

Restenosis Reduction

• DES reduce restenosis/re-occlusion compared to BMS when no contraindication to extended DAPT exists (Class I, Level A) 1
• Extended follow-up to 4 years confirms sustained benefit of DES in decreasing repeat revascularization without differences in death or MI 2

Special Clinical Scenarios

Peripheral Arterial Disease

• Iliac artery lesions: Provisional stenting (PTA with stenting for failures) is equally effective as primary stenting and more cost-effective 2
• Femoropopliteal lesions: No difference in patency between stents and PTA alone in randomized trials; stenting has higher technical success and may salvage PTA failures 2
• Short stenoses (<10cm) in femoropopliteal segment: PTA alone is adequate if good angioplasty result achieved 2
• Drug-eluting stents and drug-coated balloons show more consistent advantages in femoropopliteal segment than infrapopliteal interventions, mainly for patency and restenosis endpoints 2

Pediatric Coarctation

• Stents expandable to adult size (minimum 2cm diameter) are indicated for recurrent coarctation with gradient >20 mmHg (Class I, Level B) 2
• Reasonable to consider expandable stents for initial treatment of native coarctation in suitable anatomy 2
• Newer stent technology may mitigate size issues as patient grows 2

Cost-Effectiveness Considerations

• DES is substantially more expensive than BMS 2, 1
• However, total cost is reduced with DES due to avoidance of repeat revascularization procedures 1
• When financial resources are limited, prioritize DES for patients at greatest risk for restenosis 2

Common Pitfalls to Avoid

• Do not use DES without confirming DAPT compliance capability - this is the most critical error that leads to catastrophic stent thrombosis 2, 1
• Do not undersize stents - use intravascular imaging to ensure adequate stent expansion and apposition 2
• Do not ignore lesion preparation in calcified lesions - inadequate preparation leads to stent underexpansion and failure 2
• Do not assume all DES are equivalent - second-generation DES have superior outcomes to first-generation 1
• Do not forget high-pressure post-dilation - IVUS studies show this improves outcomes 2