The need for stent–lesion matching to optimize outcomes of intracoronary stent implantation

Abstract

Intracoronary stents have markedly improved the outcomes of catheter-based coronary interventions. Intracoronary stent implantation rates of over 90% during coronary angioplasty are common. Stent implantations are associated with a small but statistically significant number of adverse outcomes including restenosis, thrombosis, strut malapposition, incomplete strut endothelialization, and various types of stenting failure. Better matching of biomechanical properties of stents and lesions could further improve the clinical outcome of intracoronary stenting. Thus, in this article, we assess the need for advanced intracoronary stent-lesion matching. We reviewed the data on biomechanics of coronary stents and lesions to develop knowledge-based rationale for optimum intracoronary stent selection. The available technical information on marketed intracoronary stents and the current understanding of the biomechanical properties of coronary lesions at rest and under stress are limited, preventing the development of knowledge-based rationale for optimum intracoronary stent selection at present. Development of knowledge-based selection of intracoronary stents requires standardization of mechanical stent testing, communication of the nonproprietary technical data on stents by the industry and dedicated research into procedural stent-lesion interactions.

Biomechanical Behavior of Atherosclerotic Plaque

“…It is equally logical to ask whether stents respond differently to different plaque parameters, like whether the plaque has calcified regions or not (Morlacchi et al 2014). Biomechanical performance criteria are generally not available, and thus clinicians cannot select stents based on their biomechanical performance (Lanzer et al 2010(Lanzer et al , 2013. Thus, there is interest in, and need for, further research on how to best match stents.…”

“…Although these mechanisms have been identified, it must be emphasized that they are not understood. Understanding the mechanisms of plaque deformation is the necessary goal to significantly improve device technology and clinical technique and thus the long-term patency of treated vessels (Lanzer et al 2013). Angioplasty and stenting are mechanical processes, that is, they work because they force the plaque to remodel (change shape) in such a way as to increase the size of the lumen.…”

“…Lanzer et al (2013) suggest four steps to bring about more successful interventions: (1) develop standard methodologies to measure the biomechanical properties of stents; (2) industry should adopt those methods and inform interventionalists of the relevant, nonproprietary biomechanical performance data; (3) the biomechanical interactions between stents and lesions need to be researched in more depth; (4) the understanding of patient specific stent-lesion interactions needs to be applied in the clinic. Advancing the state of the practice and state of the art of stenting procedures is an important goal of the interventional community.…”

“…Besides restenosis, thrombosis, strut malapposition, and incomplete strut endothelialization, Lanzer et al (2013) identify several clinical problems, including the inability to deliver the stent or to deploy the stent fully (failed stenting), the need to use accessory techniques such as additional guide wires (difficult stenting), multiple stent interactions causing strut damage and deformation of the stents (extended stenting), inappropriate stent geometry (undersizing) or mispositioning of the stent (complicated stenting), and finally potential complications such as mechanical vessel obstruction or closure, edge or longitudinal dissections, perforations, aneurysm formation, and stent loss (injurious stenting).…”

“…Deliverability of stents to the target sites is a complex function of stent properties, lesion properties, and the interaction between the stent and lesion. Schmidt et al 2009 andLanzer et al 2013 define performance parameters that can be used to describe the deliverability of the stent: trackability, crossability, pushability and torqueability, and retractability.…”