Ten Years Of Stenting: What Next?

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Abstract
Endovascular scaffolds have been tried in animals long ago, but it took 70 years to introduce stents into clinical practice. In 1994, two major randomized trials confirmed that stenting after percutaneous transluminal coronary angioplasty (PTCA) does indeed reduce the incidence of restenosis, as well as other events like myocardial infarctions and emergency surgery. Numerous stents are now in use: self‐expanding and balloon‐expandable stents; stainless steel stents; platinum and tantalum stents; flexible and articulated stents; and lately also heparin‐coated stents. New designs with improved fluid dynamics and optimal conformability are now being used. All stents are foreign bodies, and may induce spasm and thrombosis. Meticulous drug treatment was thought to be essential in reducing the incidence of subacute thrombosis, but was associated with a significant number of local bleeding complications. Warfarin has even been suspected of favoring stent thrombosis. An optimal implantation strategy that aims at an absolutely perfect primary result, with no residual narrowing, with absence of dissections, and with complete stent expansion, has dramatically reduced both the complication rate after stenting and the need for heavy anticoagulation. The role of platelet inhibition after stenting is becoming increasingly clear. Ticlopidine in combination with aspirin is presently the recommended strategy. Polymer stents have not yet fulfilled their expectations but hold great promise as a matrix for future drug delivery systems, possibly in combination with metal. Metal stents with adequate structural properties seem to have restenosis rates of some 10%. Radioactive stents (to further reduce intimal hyperplasia) are currently in clinical investigation. In summary, stents have revolutionized the practice of transluminal angioplasty and have secured their place for the future.