What are the guidelines for choosing stents, including drug-eluting stents (DES) and bare-metal stents (BMS), for patients with coronary artery disease, considering factors such as lesion characteristics, patient demographics, and medical history, including diabetes and impaired renal function?

Stent Selection for Coronary Artery Disease

Drug-eluting stents (DES) are recommended over bare-metal stents (BMS) for all percutaneous coronary interventions, regardless of clinical presentation, lesion type, planned non-cardiac surgery, anticipated duration of dual antiplatelet therapy, or concomitant anticoagulant therapy. 1

Primary Recommendation: DES as Default Choice

• DES should be used as the standard stent type for all coronary lesions based on the most recent European Society of Cardiology guidelines, which provide a Class I recommendation for DES over BMS irrespective of patient or lesion characteristics 1
• This recommendation supersedes older guidelines that distinguished between BMS and DES based on specific clinical scenarios 1
• The superiority of DES is driven by significantly lower rates of restenosis (6-8.9% vs 26-42.3%) and target lesion revascularization (2-4.9% vs 16-22.9%) compared to BMS, with similar or lower mortality and myocardial infarction rates 1

Lesion-Specific Considerations

Small Vessel Disease (Reference Diameter 2.25-2.5 mm)

• DES demonstrate marked benefit in small vessels, reducing restenosis from 38.5-42.9% with BMS to 7.1-18.6% with DES 1
• Target lesion revascularization decreases from 15.6-20.6% with BMS to 2.7-7.3% with DES in vessels <2.5 mm 1
• Ultrathin-strut DES (60 μm) show comparable long-term outcomes to thin-strut DES (81 μm) in small vessels at 5 years 2

Diabetes Mellitus

• DES provide substantial benefit in diabetic patients, reducing restenosis from 50.5% with BMS to 17.6% with DES in all diabetic patients 1
• For insulin-dependent diabetics specifically, restenosis decreases from 50% to 35% with sirolimus-eluting stents, though this remains higher than in non-diabetic patients 1
• Target lesion revascularization in diabetic patients drops from 22.9% with BMS to 7.2% with DES 1

Long Lesions (18-40 mm)

• DES are specifically indicated for long lesions based on the TAXUS-VI trial, which demonstrated efficacy in lesions 18-40 mm in length 1
• The benefit of DES over BMS is maintained even in complex, longer lesions 1

Left Main Coronary Artery Disease

• DES show superior outcomes compared to BMS for unprotected left main disease, with 12-month major adverse cardiac events of 8-24% for DES versus 26% for BMS 1
• Target vessel revascularization at 12 months is markedly lower with DES (2-6%) compared to BMS (17%) 1
• IVUS guidance is warranted before stenting to accurately assess lesion characteristics in left main disease 1

Bifurcation Lesions

• DES are recommended for bifurcation lesions, though these were excluded from early pivotal trials 1
• Registry data support DES use in bifurcations, with dedicated bifurcation stent techniques under investigation 1

ST-Elevation Myocardial Infarction (STEMI)

• DES are reasonable as an alternative to BMS for primary PCI in STEMI (Class IIa recommendation) 1
• DES reduce target vessel revascularization rates without increasing death, myocardial infarction, or stent thrombosis compared to BMS in STEMI 1
• The HORIZONS-AMI trial showed no difference in 12-month composite safety endpoints (death, reinfarction, stroke, stent thrombosis) but lower ischemia-driven target vessel revascularization with DES 1

Critical Contraindications to DES

Inability to Comply with Prolonged Dual Antiplatelet Therapy

• BMS should be used instead of DES when prolonged clopidogrel administration (minimum 6-12 months) is unlikely or contraindicated 1
• Patients requiring major non-cardiac surgery within 12 months should receive BMS rather than DES to avoid perioperative bleeding complications while on dual antiplatelet therapy 1
• Premature discontinuation of thienopyridines is strongly associated with stent thrombosis, making adherence assessment critical 1

High Bleeding Risk

• Patients with high bleeding risk or requiring chronic oral anticoagulation require careful consideration, though DES remain recommended per current guidelines 1
• Concomitant proton pump inhibitor therapy should be added when combining dual antiplatelet therapy with anticoagulation 3

Dual Antiplatelet Therapy Requirements

• Clopidogrel 75 mg daily plus aspirin must be administered for a minimum of 6-12 months after DES implantation 1
• For NSTE-ACS, periprocedural dual antiplatelet therapy with aspirin and clopidogrel is recommended for up to 1 week initially 1
• Ticagrelor or prasugrel are not recommended as part of triple antithrombotic therapy in patients requiring oral anticoagulation 1
• After 12 months, antiplatelet treatment can be discontinued in patients treated with oral anticoagulation for atrial fibrillation 1

Stent Thrombosis Risk

• Definite or probable stent thrombosis occurs in 0.5-1.0% of DES patients at 2-3 years, comparable to or lower than BMS rates 1
• Early stent thrombosis (within 30 days) occurs in 0.3-0.7% of DES cases 1
• Late and very late stent thrombosis remain rare (0.6-1.1%) with appropriate dual antiplatelet therapy adherence 1

Sirolimus-Eluting vs Paclitaxel-Eluting Stents

• Both sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) demonstrate equivalent efficacy and safety profiles 1
• The ISAR-LEFT MAIN trial found no significant differences in death (6.6% vs 5.0%), myocardial infarction (4.6% vs 5.0%), or major adverse cardiac events (15.8% vs 13.6%) at 12 months between SES and PES 1
• Angiographic restenosis rates at 6-9 months are similar (19.4% for SES vs 16.0% for PES) 1
• Either DES type can be selected based on availability and operator preference, as clinical outcomes are comparable 1

Common Pitfalls to Avoid

• Do not use BMS to avoid medicolegal concerns—this is unfounded and not evidence-based 1
• Do not implant DES without confirming patient ability to maintain dual antiplatelet therapy for at least 6-12 months 1
• Do not discontinue clopidogrel prematurely, as this is the strongest predictor of stent thrombosis 1
• Do not assume BMS are safer in high-risk patients—contemporary evidence shows DES have similar or better safety profiles with superior efficacy 1