Timing and Considerations for Drug-Eluting Stent Placement in Cardiology

Timing for Stent Placement and Drug-Eluting Stents

Hello Dr.
Lee, my father underwent a cardiac catheterization today and had two drug-eluting stents placed.
I would like to ask you a few questions:
1.
Why can't a blocked artery just be treated with balloon angioplasty? After dilation, the artery should improve significantly compared to its original blockage, even if it narrows again later; the degree of narrowing should be at most the same as before, right?
2.
What criteria does a doctor use to decide to place a stent? Is there a minimum standard that must be met in order to proceed with stenting?
3.
There is a risk of late thrombosis with drug-eluting stents.
Could you please explain what symptoms might occur if this risk materializes?
4.
Are there any statistics on the occurrence of late thrombosis while on medication after one year or two years?
5.
What are the long-term effects of taking those two anticoagulant medications on the body?
6.
Is the most dangerous time for stent placement during the procedure itself, or should we be cautious for a week afterward? Thank you very much.
🙏

Mr. Jiang, 50~59 year old female. Ask Date: 2023/11/17

Dr. Li Han reply Cardiology

Hello, the principle of coronary balloon angioplasty is to expand and rupture the narrowed atherosclerotic plaque, resulting in a larger lumen than the original lesion.
However, this is an ideal scenario, and it is often accompanied by vascular recoil, dissection, or hematoma formation, which can severely lead to lumen occlusion due to hematoma within the dissection.
This is where stents play a crucial role.
In the era before stents, these complications could lead to more severe infarctions, mortality, or the need for emergency bypass surgery.
Under conditions of acute myocardial infarction, past studies and clinical guidelines have recommended direct stent implantation over simple balloon angioplasty.

Previously, bare metal stents faced challenges with in-stent restenosis due to excessive neointimal hyperplasia, which has been addressed in the era of drug-eluting stents, reducing the restenosis rate from 20-30% to less than 5%.
This is particularly beneficial for diffuse lesions, long lesions, or lesions with small lumens.
The incidence of stent thrombosis is about 1-1.5% in the acute phase and approximately 0.3% annually in the long term, so long-term medication is necessary.
However, the risks associated with stents remain acceptable: the bleeding risk from dual antiplatelet therapy exists, but under conditions of acute coronary syndrome, a duration of one year is currently recommended.
Of course, if anticoagulants are also used, the bleeding risk is higher and should only be applied under specific conditions.

The Changhua Hospital of the Ministry of Health and Welfare cares about you.

Reply Date: 2023/11/17

More Info

Hello! Thank you for your questions regarding drug-eluting stent (DES) placement and the associated considerations. Let's address each of your queries in detail.

1. Why can't the blocked artery just be treated with balloon angioplasty?
While balloon angioplasty can effectively open up a blocked artery, it does not provide a permanent solution. The artery can become narrowed again due to a process called restenosis, which is the re-narrowing of the artery after it has been treated. This occurs because the vessel may respond to the injury caused by the balloon by healing in a way that leads to scar tissue formation, which can cause the artery to narrow again. Drug-eluting stents are designed to release medication that helps prevent this restenosis by inhibiting the growth of scar tissue in the artery wall. Therefore, while balloon angioplasty can improve blood flow temporarily, stenting provides a more durable solution.

2. What criteria does a doctor use to decide to place a stent?
The decision to place a stent is based on several factors, including the severity and location of the blockage, the patient's symptoms, and the overall condition of the heart. Generally, if the blockage is significant (typically over 70% in major coronary arteries) and is causing symptoms such as angina or is likely to lead to a heart attack, a stent may be indicated. Additionally, if the blockage is in a critical area of the heart that supplies a large portion of the heart muscle, stenting is often preferred.

3. What symptoms might indicate a risk of thrombosis after stent placement?
Stent thrombosis is a serious complication that can occur after stent placement, particularly with drug-eluting stents. Symptoms may include sudden chest pain, shortness of breath, or other signs of a heart attack. If a patient experiences these symptoms, they should seek immediate medical attention. It is crucial to adhere to prescribed medications to minimize this risk.

4. What are the statistics regarding thrombosis while on medication?
The risk of stent thrombosis is highest in the first few months after placement, particularly if the patient does not adhere to dual antiplatelet therapy (DAPT), which typically includes aspirin and a P2Y12 inhibitor (like clopidogrel or ticagrelor). Studies suggest that the risk of stent thrombosis is about 1-2% in the first year after stent placement, but this risk decreases significantly with continued medication adherence. Long-term studies indicate that the risk remains low after the first year, especially if patients continue to take aspirin indefinitely.

5. What are the long-term effects of taking dual antiplatelet therapy?
Long-term use of antiplatelet medications can increase the risk of bleeding, including gastrointestinal bleeding and intracranial hemorrhage. Patients may also experience side effects such as bruising, dizziness, or gastrointestinal discomfort. However, the benefits of preventing stent thrombosis and cardiovascular events generally outweigh these risks. It is essential for patients to discuss any concerns with their healthcare provider, who can help manage and mitigate these risks.

6. When is the most critical time for complications after stent placement?
The most critical period for complications, including stent thrombosis, is within the first 30 days after the procedure. However, the risk remains elevated for up to a year, particularly if the patient does not adhere to their medication regimen. After this period, while the risk decreases, it is still important for patients to maintain regular follow-ups with their cardiologist and to continue taking prescribed medications as directed.

In summary, drug-eluting stents are an effective treatment for coronary artery disease, providing a long-term solution to prevent restenosis. However, careful consideration of the risks and benefits, adherence to medication, and regular follow-up care are essential for optimal outcomes. If you have further questions or concerns, please feel free to ask!

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