Anthony Bavry, R. David Anderson, William Brearley, Associate Professor, William Brearley, Fellow, and Division of Cardiovascular Medicine
Table of Contents
· A brief history of the evolution of coronary stenting with an overview of stent classification, purpose of this guide, and future direction.
2. Stent Classification
· Bare metal stents vs Drug eluting stents.
· Briefly discuss major meta-analyses and registries on the topic
· Description of currently available stents.
3. Indications for Coronary Revascularization
· Current indications for stenting (ie focal lesions, avoidance of bifurcation lesion, large vessels, non-diabetic patients, etc)
· Discussion of stenting in acute coronary syndromes.
· Role of CABG versus DES for multi-vessel disease (SYNTAX trial)
· Discussion medical therapy for stable angina (COURAGE) and medical therapy for late presentation of myocardial infarction (OAT trial)
4. Pre-catheterization Assessment
· Importance of assessment of renal function, anemia and bleeding risks, co-morbidities, current medications which may need to be held or adjusted (metformin, insulin, etc)
· Also assessment of any future surgical procedures and determination of compliance for post PCI anti-platelet therapy and its potential contribution to stent complication/thrombosis.
· Choice of intraprocedural anti-coagulation and anti-platelet therapy
· Need for embolic protection, IABP, and transvenous pacing
· Access site management
5. Stent Delivery
· Sizing and delivery basics with brief discussion of cardiac catheterization and stent delivery/deployment including available catheters, wires, etc.
· Discussion of adjunctive measures such as FFR (FAME trial) and IVUS to aid in lesion candidacy and stent guidance pre and post intervention
· Multiple illustrations
· Special lesion setups: bifurcations, ostial lesions, heavily calcified lesions, vein grafts, left main
6. Potential Complications
· Contrast nephropathy and other complications including bleeding (hematoma, vessel injury), MI/CVA, emergent coronary bypass, heart block, cardiac arrest, contrast nephropathy.
· Management of hypotension, hypertension, heart failure, and severe allergic reaction
· Specific risk of various complications for patient discussion (table)
· Discussion of risk factors for in-stent restenosis as well as acute and late stent thrombosis with a focus on the inherent differences in presentation with each
7. Medical Therapy
· Medical therapies including anti-platelet agents (including Prasugrel), beta blockers, statins, and ACE inhibitors in patients with coronary artery disease and coronary stents
· Other potential modifiers of risk including diet, exercise, weight loss, and smoking cessation.
· Maintenance anti-platelet therapy for different types of stents (BMS vs DES) and discussion of potential need for longer duration.
· Use of aspirin, clopidogrel, and warfarin in patients with atrial fibrillation/mechanical heart valves/etc.
8. Perioperative Management
· High risk periods following stent implantation
· Potential for IIb/IIa bridging
· Clopidogrel hold and re-initiation.
9. Current Controversies
· In stent restenosis
· Acute and late stent thrombosis with DES, off label use including vein grafts, duration of dual anti-platelet therapy and consequences of premature discontinuation.
10. Stress testing/surveillance
· Indications for repeat heart catheterization, stress testing
11. Future Developments
· Bioabsorbable stents, new stent delivery systems, laser and atherectomy developments, imaging technology including CT angiogram
12. Provider and Patient Resources