Commentary: Overcoming challenges with drug-eluting stents

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There are cases presented to all physicians when we have to balance benefits of a particular treatment with concerns around safety for certain patients. In interventional cardiology, we see this dilemma with drug-eluting stents (DES). While this technology provides effective therapy for many patients with ischemia-inducing coronary lesions, there are certain patient groups that encounter problems for different reasons.

A growing subset that requires special attention is diabetic patients. As type 2 diabetes is a pandemic in the U.S. and Europe with steady growth, we cannot simply see these patients as a small subset.

These patients present challenging cases in multiple areas, including a higher risk of coronary disease and higher risks for co-morbid health problems. For these reasons, they are at a higher risk than non-diabetics of developing complications.

In the short term following bare-metal stent placement, diabetic patients have demonstrated higher rates of re-narrowing of coronary arteries. As a result, physicians have used DES to improve outcomes—even though we have not seen improvements in safety or tolerance of required anti-platelet medications.

One leading problem is the impact that high blood sugar has on the arterial healing process. Hyperglycemia and any form of diabetes impairs this process and, therefore, the benefits patients may experience. It is easy to understand why it is no longer enough to approach treatment from a strictly mechanical view. Instead, it is necessary to consider the bio-mechanical aspect of intervention by optimizing angioplasty techniques while also improving the healing process post-stent implantation.

A large group of patients that also presents challenging cases are those who cannot tolerate required medication, specifically blood-thinning agents. It is standard for dual-antiplatelet therapy to be prescribed for one year following the implant of DES. In the past, we have only focused on how to use more potent blood thinners rather than reducing the need for the therapy.

Patients in a number of groups that cannot tolerate a full year of dual-antiplatelet therapy. We are often challenged, for example, when patients inform us of their need to undergo surgery during that one-year time. The prescribed therapy of blood-thinning agents may have a dangerous effect on that planned surgery. As a result, the patients have to either take on added risk or postpone operations. Improving the healing process and shortening the length of the therapy stands to help many patients.

There are new technologies that improve the healing process and have demonstrated great results in safely treating these patient groups. One such stent technology uses captured endothelial progenitor cells (EPC) to treat patients in these challenging cases. This technology has been used in my practice for over three years now with tremendous results.

The technology improves the healing process by using the EPC capture technology to speed re-endothelization. With the rate of healing accelerated, we find a decrease in the need for prolonged dual-antiplatelet therapy and its associated risks. Clinical studies continue to demonstrate benefit in these challenging patient populations. This rapid re-endothelization of the stented portion of the coronary artery is translating into improved results at all stages of the healing process.

The ability to reduce the duration of dual-antiplatelet therapy is very important. Having an option for the duration of the treatment brings significant benefit to patients and physicians. In many cases, this course of therapy is reduced from one year to one month. This reduces the risks for patients who raise concerns about bleeding, either due to needed surgeries or problems with bleeding in the past. With such options now available, we are able to offer therapy that is tailored to the specific needs and circumstances of the individual.

This technology has been used in my practice for multiple years with very few patients returning due to a failure of the artery to remain open or problems with the reduced length of dual-antiplatelet therapy. The ability to select an appropriate technology based on the patient’s needs truly presents us with a win-win situation.

Dr. Smith is a consultant cardiologist at Morriston Hospital, Swansea, U.K., focusing on interventional cardiology, specifically radial access angioplasty, intravascular ultrasound and percutaneous aortic valve replacement.