Stent Basics:

Lessons Learned
SCAI Fellows Course
December 7, 2013

Barry F Uretsky, MD
University of Arkansas for Medical Sciences
Central Arkansas Veterans Health System
Little Rock, AR
 Disclosure
I have no disclosures relevant to this
presentation. 
 Stent Basics 
• Balloon angioplasty (BA) with historical notes
• Bare metal stent (BMS) basics
• Drug eluting stent (DES) basics
‐ First generation
‐ Second generation
• Future  stent basics 
 Evolution of PCI

40

30
Event Rate

Failure
20
Em CABG
Restenosis
Stent thrombosis
10 VLST

0
BA early BA late BMS early BMS late DES
1977 1985 1994 1997 2003-present
Innovations over time
Balloon Angioplasty (BA)
 Lessons from BA  

It worked!
Acute success:  60‐70% in early series            (1979‐85)
80‐90% in later series            (1986‐93)   
 FIM Balloon Angioplasty (PTCA)

Interventional Cardiovascular Medicine. Churchill Livingstone, Inc. 1994

 FIM Balloon Angioplasty (PTCA)

“FFR”

Interventional Cardiovascular Medicine. Churchill Livingstone, Inc. 1994

Mechanisms of Recanalization with BA

vessel stretch plaque re-distribution

embolization
dissection
 Mechanism of Lumen Gain
BA vs Atherectomy (DCA)
• BA:
–81% of lumen gain was increase in vessel area (stretch)
–19% of lumen gain was reduction in plaque area
• DCA :
–22% of lumen gain was increase in vessel area (stretch)
–78% of lumen gain was reduction in plaque area

IVUS evaluation pre‐ and post‐PCI

Braden G. JACC 1994

 Lessons from  BA 

#2 Sometimes BA worked in the 
morning  but  vessel closed by  
the next day (usually at night)
Mechanism of Abrupt Closure with BA

Thrombus Formation
Mechanism of Abrupt Closure with BA

Thrombus Formation

Abrupt closure rate: 5‐8%
 Lessons from BA

#3  Aspirin  improves immediate 
outcomes 
 Randomized Trials of Aspirin in BA
% Major Ischemic 
Complications
Heparin 10,000 units

12 ASA / Dipyridamole + Heparin
12.6
Ticlopidine + Heparin

8
6.9
75%
4 77% P<0.001
P=0.0113 3.2
2.4
1.6
0
Schwartz  White 
N=376 N=337

Schwartz.  N Engl J Med 1988;318:1714         White.  Coronary Artery Disease 1991;2:757

 Lessons from BA

#4  Each type of  balloon material has specific 
advantages and limitations.

Semi‐compliant        Non‐compliant
Trackability +++                                +
Balloon expansion             +++                                +
Balloon re‐wrap                 +++                                +
Shape maintenance             +                               +++
 Lessons from BA

#5 Atherectomy alone  improves immediate 
angiographic outcomes but  not long‐term 
outcomes compared  to BA.
 Atherectomy alone  improves immediate 
angiographic outcomes but  not long‐term 
outcomes compared  to BA. 

Rotablator Laser BA
p-value
(n=231) (n=232) (n=222)

Procedural Success (%) 89 77 80 0.0019

Major In-Hospital
3.2 4.3 3.1 0.71
Complications (%)
6-Month TLR (%) 42.4 46.0 31.9 0.013

Reifart N . Circulation 1997; 96: 91-98

 Lessons from BA
#6  Long‐term outcomes show 
moderate improvement

Good news: 
1. Reasonable symptomatic improvement 
(60‐70%)
2. Low risk of sudden death or MI late after 
BA (<5%)
 Lessons from BA
#6  Long‐term outcomes show moderate 
improvement

Good news: 
1. Reasonable symptomatic improvement (60‐70%)
2. Low risk of sudden death or MI late after BA (<5%)

Not such good news:
1. Symptomatic restenosis (30‐50%)
Mechanism of Restenosis from BA

Recoil +negative remodeling               Neointimal Hyperplasia 

(70%) (30%)

Negative remodeling at 3 mos Post BA
Treatment of BA Restenosis
(pre-stenting era)

BA
 Treatment of BA Restenosis
(pre-stenting era)

BA

Acute success rate : 90+%; Long‐term patency  30‐50%
Bare Metal Stenting (BMS)
 Stenting: Why do it?
• Primary reason: prevent abrupt closure from BA
• Potential advantages
‐ Greater lumen  expansion
‐ Lower rates of acute procedural complications 
and better predictability of results
‐No recoil or negative remodeling
‐ Improvement in long‐term outcomes
 Stenting: A Strategy to Improve
Immediate Vessel Patency (and Allow Operator
Adequate Sleep)
 BMS: Why do it?
• Primary reason: prevent abrupt closure
• Potential advantages
‐ Greater lumen  expansion
‐ Lower rates of acute procedural complications 
and better predictability of results
‐No recoil or negative remodeling
‐ Improvement in long‐term outcomes
 BMS: Why do it?
• Primary reason: prevent abrupt closure
• Potential advantages
‐ Greater lumen  expansion
‐ Lower rates of acute procedural complications 
and better predictability of results
‐No recoil or negative remodeling
‐ Improvement in long‐term outcomes
 BMS: Why do it?
• Primary reason: prevent abrupt closure
• Potential advantages
‐ Greater lumen  expansion
‐ Lower rates of acute procedural complications 
and better predictability of results
‐No recoil or negative remodeling
‐ Improvement in long‐term outcomes
 BMS: Why do it?
• Primary reason: prevent abrupt closure
• Potential advantages
‐ Greater lumen  expansion
‐ Lower rates of acute procedural complications 
and better predictability of results
‐No recoil or negative remodeling
‐ Improvement in long‐term outcomes
 BMS: Why do it?
• Primary reason: prevent abrupt closure
• Potential advantages
‐ Greater lumen  expansion
‐ Lower rates of acute procedural complications 
and better predictability of results
‐No recoil or negative remodeling
‐ Improvement in long‐term outcomes
 BMS: Why do it?
• Primary reason: prevent abrupt closure
• Potential advantages
‐ Greater lumen  expansion
‐ Lower rates of acute procedural complications 
and better predictability of results
‐No recoil or negative remodeling
‐ Improvement in long‐term outcomes
Is It Possible to Implant a Permanent  
Coronary Prosthesis Safely? 

Serruys P. NEJM 1991; 324:13‐17
Is It Possible to Implant a Permanent
Coronary Prosthesis Safely?

Editorial by Dr Peter Block accompanying Serruys article:

“The development of these devices has resembled the mating

of elephants, carried out on a high level and associated with
much noise and trumpeting, with the results not evident for
two years and the product not perfect”.

Block P. NEJM 1991; 324:28‐29
How to Prevent Acute Stent Thrombosis circa 
1993‐1996 ?

Heparin                           
Dextran
ASA
Coumadin
How to Prevent Acute Stent Thrombosis circa 
1993‐1996 ?
Bleeding complications and transfusions were frequent!!
 Implanting a Stent Safely:
The Big Advances 1995-1996

• Dual antiplatelet therapy

• High-pressure implantation
 Implanting a Stent Safely:
The Big Advances 1995-1996

• Dual antiplatelet therapy

• High-pressure implantation
High-Pressure Inflation is Necessary for
Adequate Stent Expansion
Baseline
3.5 NC 10 atm 3.5 NC 15 atm

Colombo A et al. Circulation 1995;91:1676-1688

High-Pressure Inflation is Necessary for
Adequate Stent Expansion
Baseline
3.5 NC 10 atm 3.5 NC 10 atm

Title of Article: “Intracoronary

Stenting Without Anticoagulation
Accomplished With Intravascular
Ultrasound Guidance”

Colombo A et al. Circulation 1995;91:1676-1688

 Efficacy of DAPT (Thienopyridine +ASA) in
Reducing MACE after Stenting
Hall (1996)1
0.8 P=0.1 ASA + Ticlopidine
N=226 3.9 ASA only

P=0.01 ASA + Warfarin

ISAR (1997)2 1.6
N=517 6.2

STARS (1998)3 0.5

N=1653 3.6 P<0.001
2.7
P=0.07
MATTIS (1998)4 5.6
N=350 11.0

FANTASTIC (1998)5 P=0.37

5.7
N =485 8.3

0 3.0 5.0 8.0 12

Cumulative Event Rate (%)

1 Hall P. Circulation. 1996;93:215‐222;  2 Schömig A. N Engl J Med. 1996;335:1084‐1089; 3.  Leon M. N Engl J Med. 1998:339:1665‐71; 

4 . Urban P. Circulation. 1998 98:2126‐2132; 5. Bertrand M. Circulation. 1998;98:1597‐1603.
STARS Trial

Leon MB et al. NEJM 1998; 339:1665. 
 Lesson from BMS

#1 BMS can be used safely as a primary

treatment modality if DAPT and high-
pressure inflation are used.
 Lessons from BMS

#2 BMS show less TVR than BA but no significant 
decrease in late MI or death.
 BMS vs BA
Angiographic Parameters
STRESS n=410 BENESTENT     n=520
mm P<.001 P<.001 p=0.01 mm P<.001 P<.001 p=0.09
2 2
1.72

1.5 1.5 1.40

1.23
0.98 0.97
1 1
0.74 0.80 0.75
0.65 0.65
0.5 0.38 0.5
0.32

0 0
acute lumen late lumen net gain acute lumen late lumen net gain
gain loss gain loss
stent
Fishman  DL. N Engl J Med 1994 BA Serruys P. N Engl J Med 1994
 BMS vs BA
Long-term Outcomes
STRESS n=410 BENESTENT     n=520
% p=0.16 p=0.06 p=0.046 % p=0.02 p=0.001 p=0.02
50 50
42.1
40 40
31.6 32
29.6
30 30
23.8 23.3 22
19.5 20.1
20 20
15.2
13.5
10.2
10 10

0 0
MACE TLR restenosis MACE TLR restenosis
at 12 mo. stent at 7 mo.

Fishman  DL, N Engl J Med 1994 PTCA Serruys  P, NEJM 1994;331:489‐495.

Mechanism of Opening and Restenosis
wth BMS
NIH

Opening: Enlarging and scaffolding  vessel Restenosis=neointimal hyperplasia (NIH)     

Late loss with BMS typically in 0.8 – 1.2 mm range.
Each BMS is unique 
Stent design

Bare-
Metal
Stent

Delivery balloon catheter

 Each BMS is unique 
Stent design
Stent Design Delivery catheter

Flexibility Trackability
Radial strength Stiffness
Radiopacity Balloon material
Material
Strut thickness
Bare- Balloon compliance

Metal
Profile
Profile Rewrap 
Conformability
Degree of coverage Stent
Uniformity of coverage
Side branch access
Biocompatibility

Delivery balloon catheter

 Why cobalt chromium?
Cobalt alloy is 45% stronger than stainless steel – allowing thinner struts 
while maintaining radial strength

• More fatigue and corrosion resistant than stainless steel

• Denser than stainless steel resulting in increased radio-opacity
Conformability: Managing Lesions in Tortuous
Vessel

Closed Cell  Modular 
Design #1 Design #1

Modular 
Closed Cell  Design #2
Design #2
 Major Risk Factors for BMS Restenosis

• Longer stent length
• Smaller diameter vessel
 Major Risk Factors for BMS Restenosis
Restenosis (%)

Long stent
length

2)
Small vessel Minimal
Final in-stent
Minimum area (mm
Stent Area (mm2)

de Feyter P . Circulation 1999;100:1777-83

 Major Risk Factors for BMS Restenosis

• Longer stent length
• Smaller diameter vessel
• Diabetes
 Major Risk Factors for BMS Restenosis
Diabetics vs Nondiabetics

P=0.001
OR=1.6
1.4-1.9
P=ns P=0.02 P=0.001 P<0.001 P<0.001

N=230 N=300 N=84 N=2255 N=1439 N=4808

 Major Risk Factors for Restenosis
with BMS
• Longer stent length
• Smaller diameter vessel
• Diabetes
• Thicker struts
 Thin-Strut Versus Thick-Strut Stents
Thin struts (<100 µm):
Palmaz-Schatz Restenosis rate
ACS MULTI-LINK %
BiodivYsio p<0.001
BeStent
40
JOSTENT Flex 36.6
Diamond (Phytis) 30
V-Flex (Global Therapeutic) 28.5
Sorin Carbostent 20

Thick struts (≥100µm): 10

NIR
ACS Duet 0
BX Velocity thin struts thick struts
AVE-II (n=505) (n=436)
Cordis Crossflex LC retrospective analysis of 941 patients
Bard XT
Briguori  C. J Am Coll Cardiol 2002
 Independent Risk Factors for BMS Restenosis
Diabetes 16
Hypertension 7 3370 patients
Complex lesion 14
CTO 5
Restenotic lesion 14
Long lesion 5
Severe stenosis 11
Overstretch 5
Small vessels 84
Total stent length 29
Stent type 61
(worst vs. best)
0 1 2 3 4 5 0 20 40 60 80 100
odds ratio relative power (χ2)

Kastrati A, Am J Cardiol 2000
 Lesson from BMS
#3 Even in presence of DAPT and deployment 
with high‐pressure inflation, stent thrombosis 
may occur.
Academic Research Consortium (ARC)
Definition of Stent Thrombosis
ARC Classification
• Definite – ACS + angiographic or autopsy 
confirmation
• Probable – Any unexplained death within 30 
days or acute MI of TV territory without 
angiography or confirmation of other culprit
• Possible – Any unexplained death beyond 30 
days
 BMS Stent Thrombosis is Multi-Factorial

Lesion Technical
Complexity, disease, healing: Operator:
• Long lesions • Underexpansion
• Small vessels • Incomplete wall apposition
• Multi-vessel • Residual dissection
• AMI
• Diabetics
• Bifurcations
Stent
Thrombosis
Patient
Premature Antiplatelet
Discontinuation
-Patient compliance
-Non-cardiac surgery
-DAPT intolerance
resistance/intolerance
Modified from Honda and Fitzgerald, Circulation 2003:108, 2
Kereiakes D., et. al Rev Cardiovasc Med: 2004; 5 (1): 9-15
 BMS Stent Thrombosis is Multi-Factorial

Lesion Technical
Complexity, disease, healing: Operator:
• Long lesions • Underexpansion
• Small vessels • Incomplete wall apposition
• Multi-vessel • Residual dissection
• AMI
• Diabetics
• Bifurcations
Stent
Thrombosis
Patient Avoid stent
Premature Antiplatelet
Discontinuation
-Patient compliance
regret!!
-Non-cardiac surgery
-DAPT intolerance
resistance/intolerance
Modified from Honda and Fitzgerald, Circulation 2003:108, 2
Kereiakes D., et. al Rev Cardiovasc Med: 2004; 5 (1): 9-15
Case Example: Baseline
Pre

Courtesy of
J Hermiller
Case Example: Balloon underexpansion

Courtesy of
J Hermiller
Case Example: Post-Stenting

Courtesy of
J Hermiller
Case Example: Early Stent Thrombosis

Courtesy of
J Hermiller
 BMS vs BA
Improvement in Outcomes

Abrupt closure/                Death                       MI                       TVR           
Acute stent thrombosis

SIHD                               BMS                                ND                        ND BMS

UA/NSTEMI                  BMS                                ND                        ND BMS

STEMI                            BMS                                ND                        ND BMS
Who should Preferentially Receive
BMS (vs DES)?
Who should Preferentially Receive BMS?

• Poor 
compliance
–Stubborn
–Unreliable
Who should Preferentially Receive BMS?

• Propensity to Bleeding
Who should Preferentially Receive BMS?:
Surgery Soon
Who should Preferentially Receive BMS?

“Low  risk for restenosis” patients???

Definition of “low risk”=large vessel, 
short lesion in a non‐diabetic.
Who should Preferentially Receive BMS?

LOW RISK FOR RESTENOSIS PATIENTS???

P=0.06 P <0.001

Death/MI TVR

Kaiser  C. NEJM 2010; 363:2310‐19
 Who should Preferentially Receive BMS?

LOW RISK FOR RESTENOSIS PATIENTS???

Washington State Health Care Authority (Health Technol Assessment):

Drug eluting stents are not covered in non‐diabetics  for:
a. Stent diameter >3 mm ;
b. Stent length  <15 mm in length placed within a single vessel
Drug Eluting Stents (DES)
 Lesson from DES
#1Each DES is unique and more complex than 
BMS
 Each DES is unique and more complex 
than BMS
Stent design

Drug-
Pharmacologic Drug carrier
agent Eluting vehicle
Stent

Delivery Balloon Catheter

1st and 2nd Generation DES Stent Platforms
Diffferent drug and significantly thinner stent struts
First Generation    Second Generation   

Cypher (SES) Taxus Express (PES) ZES EES

Strut Thickness Strut Thickness Strut Thickness Strut Thickness

140um 132um 91um 81um

Alloy Alloy Alloy Alloy
Cobalt or Plt
Stainless Steel Stainless Steel       Cobalt Nickel
Chrom
 Lesson from DES

#2 1st generation DES shows similar 
incidence of death/MI and less TVR vs BMS 
 1st generation DES show similar incidence of 
death/MI and less TVR vs BMS

Mortality Repeat Revascularization

HR (95% CI) HR (95% CI)
SES vs BMS 1.00 (0.82‐1.25) 0.30 (0.24‐0.37)

PES vs BMS 1.03 (0.84‐1.22) 0.42 (0.33‐0.53)

SES vs PES 0.96 (0.83‐1.24) 0.70 (0.56‐0.84)

0∙2 0∙5 1 2 5 0∙2 0∙5 1 2 5

Stettler C . Lancet 2007;370:937‐48
 Stent Thrombosis is Multi-Factorial

Lesion Technical
Complexity, disease, healing: Operator:
• Long lesions • Under expansion
• Small vessels • Incomplete wall apposition
• Multi-vessel • Crush technique
• AMI
• Diabetics
• Bifurcations
Stent
Thrombosis
Patient DES
Premature Antiplatelet Injury & healing:
Discontinuation • Strut thickness
• Plavix compliance • Stent design
• Upcoming surgery (scaffolding/conformability)
• Plavix resistance/intolerance • Polymer
• Drug and elution profile
Modified from Honda and Fitzgerald, Circulation 2003:108, 2
Kereiakes D., et. al Rev Cardiovasc Med: 2004; 5 (1): 9-15 • Stent delivery system
 Incidence and Predictors of Thrombosis after
Successful DES Implantation

Univariate Predictors of Cumulative Stent 
Premature Antiplatelet
Therapy Discontinuation
Thrombosis
Prior Brachytherapy

Renal Failure

Bifurcation with 2 Stents

Bifurcation Lesion

Unprotected Left
Main Artery

Diabetes

0 10 20 30 40
Incidence of Stent Thrombosis
Hazard Ratio for ATP Discontinuation = 89
Iakovou I et al. JAMA. 2005;293:2126-2130.
2nd generation DES show better outcomes 
and safety  vs 1st generation DES
SPIRIT II, III, IV and COMPARE trials
Pooled database analysis (n=6,789)
Cardiac death or MI
EES (n=4,247)
10 PES (n=2,542)
HR: 0.60 [0.48, 0.74]
Cardiac Death or MI (%)

8
p<0.001 6.6%
6

4 4.0%

0
0 3 6 9 12 15 18 21 24
Time in Months
Number at risk
XIENCE 4247 4117 4011 3918 3402
TAXUS 2542 2409 2346 2280 2037
SPIRIT II, III, IV and COMPARE trials
Pooled database analysis (n=6,789)
Ischemic TLR
EES (n=4,247)
10 PES (n=2,542) HR: 0.60 [0.48, 0.75]
Ischemic TLR (%)

P<0.001
6.6%
5 4.7%

4.1%

2.3%

0 3 6 9 12 15 18 21 24

Time in Months
Number at risk
XIENCE 4247 4143 4004 3891 3363
TAXUS 2542 2416 2328 2260 2018
SPIRIT II, III, IV and COMPARE trials
Pooled database analysis (n=6,789)
Stent thrombosis (ARC definite/probable)

3
EES (n=4,247) HR: 0.30 [0.19, 0.47]
PES (n=2,542) p<0.001
ARC def or prob (%)
Stent thrombosis

2.3%
2

0.7%

0 3 6 9 12 15 18 21 24

Time in Months
Number at risk
XIENCE 4247 4177 4082 3998 3479
TAXUS 2542 2463 2408 2350 2110

Kereiakes DJ et al. EuroIntervention 2011:7:74-83

 Bern‐Rotterdam Cohort Study

5 ARC Definite ST @ 4 Years
Cumulative incidence (%)

EES vs. SES HR* = 0.41, 95% CI 0.27–0.62, P<0.0001

4 EES vs. PES HR* = 0.33, 95% CI 0.23‐0.48, P <0.0001
Paclitaxel Stent 4.4%
3
Sirolimus Stent 2.9%
2
Everolimus Stent 1.4%
1

0 0 6 12 18 24 30 36 42 48
No. at risk Months after index PCI
PES 4214 3916 3797 3176 2905 2344 1880 1077 686
SES 3784 3913 3793 3284 2604 1856 1041 2118 208
EES 4135 3617 3569 3499 3404 3080 2521 514 1734

*from Cox proportional hazards model Räber L, ESC 2011

 Definite Stent Thrombosis at 3 years
ZES vs EES

Resolute All-Comers Trial

Resolute ZES (n = 1120) Xience V EES (n = 1130)
ARC Definite ST (%)

P = 0.10 P = 0.01 P = 0.29 P = 0.73

Definite ST Early ST Late ST Very Late ST

(3yr) (<30days) (31‐360 days) (>1yr)

Silber S. Lancet. 2011;377:1241-7

Newer DES may produce new issues
 Longitudinal stent deformation
Angiographic patterns

Longitudinal
elongation with
pseudo-fracture
Longitudinal
compression

Longitudinal
Longitudinal compression
compression

• Longitudinal stent compression: Manifests itself as a dark band in 
the region of compression (also called stent “accordion”, “concertina”, 
“wrinkling”, etc.)
• Longitudinal stent elongation: Appears like a fracture in the stent 
(pseudo‐fracture)
 DES vs BMS vs BA
Improvement in Outcomes

Abrupt closure/                Death                       MI                       TVR           
Acute stent thrombosis

SIHD                        BMS=DES                             ND                        ND DES

UA/NSTEMI           BMS=DES                              ND                       ND DES

STEMI                     BMS=DES                              ND                       ND DES
The Next PCI Era?
 The Next PCI Era?
(Actually It’s Already Here…But Not in US)
The Next PCI Era?

• Bioresorbable vascular
scaffold (BVS)

• Biodegradable polymer
• Polymerless stents

• Drug-eluting balloon
(DEB)
The Next PCI Era?

• Bioresorbable vascular
scaffold (BVS)

• Biodegradable polymer
• Polymerless stents

• Drug-eluting balloon
(DEB)
What is the Minimum Duration of Radial Scaffolding?
After DES Placement, Scaffolding of the Vessel is Only a Transient Need

Quantitative angiographic study in 342 consecutive patients at 1, 2, 3, and 4 months
n = 342 patients (n = 93 at 30‐day F/U; n = 79 at 60‐day F/U; n = 82 at 90‐day F/U; n = 88 at 120‐day F/U)

p < 0.00001

p < 0.00001

The lumen appears to stabilize approximately three months after PTCA.

Serruys PW, et al., Circulation 1988; 77: 361.

 Possible Advantages of BVS

1. Restore normal vasomotor response

2. Restore normal shear stress and cyclic strain
3. Restore normal vessel curvature
4. Reduce late “stent” thrombosis
5. Reduce duration of DAPT use
6. Reduce risk of very late polymer reactions
7. Avoid/decrease positive remodeling and late stent malapposition
8. Avoid late strut fractures
9. Avoid/decrease in-stent neoatherosclerosis
10. Facilitate re-intervention by un-jailing of previously jailed side branches
11. Allow non-invasive follow-up with MRI/CT
12. Use in pediatric cases where vessel growth is expected
13. Provide the emotional appeal of “normalized “ uncaged vessel architecture
 Bioresorbable Vascular Scaffolds (BVS)
Igaki-Tamai PLLA
(1st human implant)

Abbott Absorb PLLA (w/PDLLA coat

eluting everolimus)

Iodinated tyrosine-
Reva ReSolve derivative (eluting
sirolimus)

PPLLA (eluting
Elixir DESolve myolimus)

Magnesium (eluting
Biotronik Dreams paclitaxel)
 ABSORB  BVS: OCT Results
Post-stenting 24-month

Complete strut apposition Smooth endoluminal lining 

Struts largely disappeared although 
remnant just visible (arrow)
Serruys PW .  Lancet 2009;373:897‐910.
ABSORB BVS: 12 Month Angiographic Results
In-
N=56 Proximal Distal
scaffold
Minimal Luminal
Diameter

Post procedure 2.43 2.27 2.18

At 12 months 2.30 2.00 2.10

P value 0.003 <0.001 0.047
Late Loss, mm 0.12 0.27 0.07

Diameter Stenosis, %

Post procedure 13 15 15
At 12 months 12 21 13
P value 0.75 <0.001 0.10
Binary restenosis 0% 3.57% 0%
Serruys PW .  Lancet 2009;373:897‐910.
ABSORB QCA showed no change in
Late Loss between 6 mo and 2 yrs

6 Mo 2 Yr p= ( 6 mo vs 2 yr)
n 26 19
In stent RVD 2.43 ±
(mm) 2.64 ± 0.44 0.33 0.006
In stent MLD 1.76 ±
(mm) 1.89 ±0.31 0.35 0.233
In stent DS (%) 27 ± 14 27 ±11 0.808
In stent late 0.48 ±
loss(mm) 0.43 ±0.37 0.28 0.233
In-stent binary
restenosis (%) 7.7% 0.0% (0/19) 1.000
ABSORB QCA showed no change in
Late Loss between 6 mo and 2 yrs

6 Mo 2 Yr p= ( 6 mo vs 2 yr)
n 26 19
In stent RVD 2.43 ±
(mm) 2.64 ± 0.44 0.33 0.006
In stent MLD 1.76 ±
(mm) 1.89 ±0.31 0.35 0.233
In stent DS (%) 27 ± 14 27 ±11 0.808
In stent late 0.48 ±
loss(mm) 0.43 ±0.37 0.28 0.233
In-stent binary
restenosis (%) 7.7% 0.0% (0/19) 1.000
ABSORB: Serial IVUS changes to 2 yrs
Post‐stenting 6 months

Post‐stent to 6 months

1. EEL unchanged (blue line)
2. Luminal reduction (16%)
a. stent shrinkage (11%)
b. NIH (red)  (5%)
ABSORB: Serial IVUS changes to 2 yrs
Post‐stenting 6 months 2 years

Post‐stent to 6 months Between 6 mos‐2 yrs 

1. EEL unchanged (blue line) 1.    Lumen (black) increased
2. Luminal reduction (16%) 2.    Plaque +media decreased 
a. stent shrinkage (11%) 3.    No negative remodelling  
b. NIH (red)  (5%) 4.    Stent no longer seen
 ABSORB BVS:Vasomotion studies

►The “stented” segment is able to expand and

contract .
►There is the potential in an individual patient for
normal response to physiological stimuli eg
vasodilatation in response to ischemia
 Stent Basics
Conclusions 
• Current DES have appreciably improved safety and
efficacy profiles compared to 1st generation
devices.

• By utilizing small amounts of a bioabsorbable

polymer, polymer-free systems, or fully
bioresorbable scaffolds, future generation DES will
likely further reduce stent thrombosis and improve
late outcomes.
Thanks for Your Attention!!