Coronary Stent

From Anvita Health Wiki

Contents 1 Introduction 2 Indications 3 Clinical-significance 4 Procedure 5 Complications 6 Management 7 Notes 8 More General Terms 9 Additional Terms 10 References

Introduction

• Use of a prosthetic metal device ( coronary stert) to provide & maintain an enlarged coronary lumen at the side of an obstructive atherosclerotic plaque. Used in conjection with ( PCI/ PTCA).

Indications

• reduction in coronary restinosis
• reperfusion of coronary stenosis within 12 hours of ST segment elevation myocardial infarction ( STEMI)*

• * reduction of infarct size if performed with 48 hours of STEMI [5]

Clinical-significance

• drug-eluting stents inhibit regrowth of endothelial cells that quickly conver bare metal stents
• overgrowth of endothelial cells can clog stents while exposure of the stent increases risk of clots

Procedure

• insertion of a 15-30 mm expandable tube across a lesion opened by balloon angioplasty during PTCA may diminish the rate of restenosis (2-7%) [2]

Complications

• late thrombosis more common in patients with drug-eluting stents [11,14]

• clopidogrel may need to be continued for 18 months [11]

• incidence of early thrombosis is 1.1% with placement of sirolumus-eluting stent, then 0.6%/year thereafter [14]
• late incomplete stent apposition & delayed endothelialization are mechanistic factors in late drug-eluting stent thrombosis [16]
• coronary aneurysm after drug-eluting stent (rare) [24]

Management

• clopidogrel 75-150 mg QD or prasugrel indicated for 1 year following placement of stent* [8,28]

• at least 1 month for bare metal stent
• at least 3 months for sirolilus-eluting stent
• at least 6 months for paclitaxel-eluting stent

• clopidogrel generally given with 81 mg of aspirin QD [28]

• addition of cilostazol 100 mg QD may enhance platelet inhibition [27]
• esomeprazole more effective than famotidine in preventing GI bleed [30]

• ticagrelor ( Brilinta) is more effective clopidogrel with similar bleeding risk [31]
• patients with atrial fibrillation, venous thromboembolism or mechanical heart value [25]

• clopidogrel + aspirin 81 mg to prevent white clot + warfarin to prevent red clot
• bare metal stent requires shorter antiplatelet therapy duration than drug-eluting stent (4 weeks vs 1 year)

• postpone MRI until 8 weeks after stent placment [8]
• postpone elective surgery for: [20]

• 4-6 weeks for recipients of bare-metal stents
• >= 12 months for recipients of drug-eluting stents

• urgent surgery: [20]

• discontinue clopidogrel
• continue aspirin unless significant risk of bleeding

• * no bleeding risk

Notes

• Drug-eluting stents: (2007) [15]

• FDA has approved sirolimus-eluting stents to further diminish the rate of restenosis. [3,4]
• sirolimus-eluting stents are better than paclitaxel-eluting stents [6,9,18] or bare stents [12,18,19]
• superiority of sirolimus-eluting stent sustained for at least 5 years [23]
• cost-effectivenss of drug-eluting stents in question [22]
• sirolimus-eluting stents are better than zotarolimus- eluting stents [26]
• cobalt- chromium everolimus-eluting stents (CoCr- EES) carry lower risks for thrombosis than other types of stents [28]

• stent manufacturers

• Taxus, Boston Scientific Corp.
• Cypher, Johnson & Johnson's Cordis Corp.

• New stents in development: [15]

• a stent to dissolve leaving nothing behind to trigger thrombosis, [17] contains Mg+2
• a stent that elutes cbemotactic factor(s) for arterial repair
• a super-thin stent that uses a novel drug to prevent formation of scar tissue

More General Terms

• vascular surgery
• cardiac surgery (heart surgery)
• vascular stent/vascular stenting

Additional Terms

• Arterial Revascularization Therapy Study (ARTS)
• coronary stent (PCI) vs CABG
• percutaneous transluminal coronary angioplasty (PTCA, percutaneous coronary intervention, PCI)

References

1. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
2. Journal Watch 23(13):106-7, 2003 Brophy JM et al, Ann Intern Med 138:777, 2003 King SB III, Ann Intern Med 138:824, 2003
3. Journal Watch 23(14):110, 2003 Lemos PA et al, J Am Coll Cardiol 41:2093, 2003
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15. Associated Press, March 24, 2007
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19. Baumgart D et al, One-year results of the SCORPIUS study: A German multicenter investigation on the effectiveness of sirolimus-eluting stents in diabetic patients. J Am Coll Cardiol 2007, 50:1627 PMID: [31]
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27. Jeong Y-H et al Adding cilostazol to dual antiplatelet therapy achieves greater platelet inhibition than high maintenance dose clopidogrel in patients with acute myocardial infarction: Results of the Adjunctive Cilostazol versus High Maintenance Dose Clopidogrel in Patients with AMI (ACCEL-AMI) study. Circ Cardiovasc Interv 2010 Feb 1; 3:17. PMID: [44]
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coronary stent/coronary stenting