EditorialA Brief History of Coronary Artery StentsBreve historia de los stents coronarios
Section snippets
INTRODUCTION
No specialty in the history of medicine has seen such rapid growth and innovation as interventional cardiology, due to a combination of the compelling need for better results in the treatment of coronary artery disease (CAD), the first cause of death worldwide, and the unique personality of remarkable individuals driving progress.
Since its first application in peripheral atherosclerosis in 1963 and the first coronary angioplasty in 1977, the field of interventional cardiology has evolved and
WHY IS PLAIN BALLOON ANGIOPLASTY NOT ENOUGH?
In 1963, Dotter and his trainee, Judkins, accidentally “recanalized” an occluded iliac artery while performing an abdominal aortogram. One year later, they intentionally used a catheter for the first successful percutaneous transluminal peripheral angioplasty. More than a decade later, in 1977, Gruentzig performed the first balloon percutaneous transluminal coronary angioplasty (or POBA, plain old balloon angioplasty, as it was later called) in a conscious man, starting a revolution in the
STENT STRUCTURE AND DESIGN
Coronary stents were developed to prevent arterial recoil and restenosis after balloon dilatation. Stents can be classified into 3 large families: bare metal stents (BMS), drug-eluting stents (DES), and bioresorbable vascular scaffolds (BRS).
An ideal metallic stent should have good flexibility and deliverability, low thrombogenicity, strong radial force, good radio-opacity under fluoroscopy, and good biocompatibility to ensure low rates of neointimal hyperplasia and stent thrombosis during
BARE METAL STENTS
In 1986, Puel and Sigwart set another milestone in the history of PCI by independently implanting the first self-expanding coronary stent (Wallstent, Schneider AG, Bulach, Switzerland). The following year, Palmaz and Schatz developed a balloon-expandable stent (Palmaz-Schatz, Johnson&Johnson, New Brunswick, New Jersey), which became the first Food and Drug Administration (FDA)-approved stent in the United States.
The first stents were made from stainless steel and, despite their thick struts and
DRUG-ELUTING STENTS
Since the identification of neointimal hyperplasia as the major determinant of ISR, the application of antiproliferative agents was the logical answer. Subsequently, in addition to acting as permanent vascular scaffolds, stents soon evolved to become efficient local drug delivery platforms. In 1999, Sousa implanted the first DES in Brazil, signaling the third revolutionary paradigm shift in the history of interventional cardiology.
DO BARE METAL STENTS STILL DESERVE A PLACE IN THE CATH LAB?
Drug-eluting stents clearly offer an advantage over BMS with regard to restenosis. Randomized trials and registries have consistently shown the superiority of second-generation DES over BMS regarding clinical and angiographic restenosis (Table 1), with reduced rates of repeat revascularization and ST events, but comparable clinical outcomes (in terms of death and spontaneous MI), as recently shown by the NORSTENT trial.28 Despite this clear advantage, the long-term safety of DES relies on long
CONCLUSION AND FUTURE DIRECTIONS
There is no way we could have foreseen the impact of our work so many years ago. Coronary artery stenting is the treatment of choice for CAD. With the advent of stents, the mechanical contribution to restenosis and acute recoil have been solved, making emergency bypass surgery a thing of the past. A large body of evidence has demonstrated a significant improvement in coronary stent safety and efficacy with device evolution, making second-generation DES the treatment of choice for patients
CONFLICTS OF INTEREST
None declared.
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