Lesion morphology, vessel anatomy and the outcome of coronary stenting: insight from the TWENTE trials

Destabilization of atherosclerotic plaque involves complex pathofysiological mechanisms which can lead to tromboembolism. Imaging techniques targeting these mechanism such as near-infrared fluorescence with scVEGF/Cy5.5 may be promising diagnostic tools for the risk assessment in cardiovascular diseases. Treatment of obstructive coronary artery disease with percutaneous coronary interventions has undergone major improvements, in particular since the introduction of drug-eluting stents. The use of second-generation drug-eluting stents has resulted in a generally favorable outcome in patients with challenging features of coronary anatomy as well as lesion configuration and location. This includes patients with a left dominant coronary system, bifurcation lesions, or lesions that involve the right aorta-ostial segment. While periprocedural myocardial infarction still occurred more frequently in patients with left coronary dominancy, patients with co-morbidities or complex lesions, and patients treated for a bifurcation lesion, the occurrence of periprocedural myocardial infarction appeared not to be associated with a worse long-term prognosis. The Syntax score might be a promising tool for identifying patients at risk of periprocedural myocardial infarction. Despite technical improvements of newer drug-eluting stent, the increased atherosclerotic disease burden seems to be an important predictor of an increased risk of repeat revascularization, for instance in patients who require stenting that involves the right aorta-ostial segment or in patients who had previously undergone coronary artery bypass grafting and now require a percutaneous intervention in a vein graft lesion. Highly deliverable drug-eluting stents has further improved the treatment of patients who require a percutaneous coronary intervention. The Resolute Integrity and Promus Element are such stents and demonstrated similarly efficacious and safety with excellent clinical outcomes in the DUTCH PEERS trial, even in the high-risk sub-population of patients who were treated for an acute myocardial infarction. In addition, follow-up beyond 1 year shows that the incidence of adverse clinical endpoints remained similar and low for both study devices and that the vast majority of the study population was free from chest pain. The upcoming BIO-RESORT trial, which assessed two novel biodegradable polymer-coated stent will provide insights into the clinical outcome of modern drug-eluting stents that may be highly relevant for further improvement of drug-eluting stents.