The role of drug-eluting stents for the treatment of coronary chronic total occlusions

Abstract

First generation drug-eluting stents (DES) had a major impact on our capacity to percutaneously treat coronary chronic total occlusions by significantly reducing the risk for in-stent restenosis compared to bare metal stents. Second generation drug-eluting stents further improved our capacity to treat these complex lesions by providing improved deliverability and enhanced efficacy and safety. The ongoing development of bioabsorbable stents will likely be the next major advancement to improve the durability of chronic total occlusion interventions.

Keywords::

• chronic total occlusion
• drug-eluting stents
• percutaneous coronary intervention

Financial & competing interests disclosure

ES Brilakis has received consultant/speaker honoraria from St Jude Medical, Terumo, Janssen, Sanofi, Abbott Vascular, Asahi and Boston Scientific; research support from Guerbet; spouse is employee of Medtronic. S Garcia has received consultant honoraria from Medtronic. S Banerjee has received research grants from Gilead and the Medicines Company; consultant/speaker honoraria from Covidien and Medtronic; ownership in MDCARE Global (spouse); intellectual property in HygeiaTel. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • First generation drug-eluting stents (DES) had a major impact on our capacity to percutaneously treat coronary chronic total occlusions (CTOs) by significantly reducing the risk for in-stent restenosis compared to bare metal stents.

• • Second generation DES further improved our capacity to treat these complex lesions by providing improved deliverability and enhanced efficacy and safety.

• • Even with DES restenosis continues to be relatively high compared to non-CTO lesions: approximately 10–15% in most studies, hence additional treatment strategies are needed to further improve outcomes.

• • Extensive dissection/re-entry crossing strategies (such as the Subintimal Tracking and Re-entry–STAR technique) are associated with high-restenosis and reocclusion rates and should only be used as a last resort.

• • Twelve months of dual antiplatetet therapy are currently recommended after CTO stenting, however the optimal duration remains to be determined.

• • The ongoing development of bioabsorbable stents is likely to be the next major advancement in CTO percutaneous coronary intervention.