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Commentary
Provisional Stenting Versus Routine Stenting: Is it Worth the Price?<br />
November 2003
On September 16th, 1977, Andreas Gruentzig performed the first coronary angioplasty on a 38-year-old man with a discrete proximal left anterior descending artery lesion. The procedure was a success, and the field of interventional cardiology was born.1,2 Percutaneous coronary intervention (PCI) grew over the next 25 years to become the dominant mode of coronary revascularization with over 1 million annual procedures performed in the United States alone. Even with its success, PCI remains in a constant state of technological evolution. The challenge for the interventionalist is to decide when is the right time to adopt a new technology, in which patients, and at what cost.
One of the most important changes in PCI technology has been the introduction of coronary stents. The coronary stent, a self-expanding stainless steel scaffold, was initially proposed as a bail-out technology to prevent abrupt closure and the need for emergency coronary bypass surgery.3,4 Further studies demonstrated that stents significantly reduced late restenosis when compared to balloon angioplasty.5,6 Four trials found a 30% decrease in repeat target vessel revascularization at 6 months.7 These developments led to the rapid adoption of coronary stents in community practice.8
However, stents initially added more than $3,200 to a coronary procedure.9 These added costs encouraged physicians to attempt to identify patients whose likelihood for restenosis was low and thus might do well without stent implantation. Factors such as lesion length, diameter stenosis at the completion of the intervention, and lesion location were found to predict patients whose likelihood of repeat revascularization was low, around 14%, and thus equivalent to stented patients.10 This work led to a hotly contested debate on whether eligible patients should routinely receive stents or should the technology be reserved for higher risk patients only (so-called provisional stenting strategy).
This is the question addressed by Mehta et al. in this issue of the Journal of Invasive Cardiology. Specifically, the authors review 322 consecutive patients treated by two operators with different
See Mehta et al. on pages 630–633
practice styles, one using routine stenting (71% of cases ) versus a provisional stent advocate (49% of cases). The authors reported that outcomes (death, repeat PTCA, bypass surgery, and overall major adverse cardiac events at in-hospital and 1-year follow-up) were similar for these two interventionists. They conclude that provisional stenting is as efficient a strategy as the routine use of stents.
While the authors are commended for their intellectual curiosity and willingness to collect and analyze their results, the study has a number of limitations. Although the patient characteristics were listed at baseline, unmeasured variables such as vessel size intervened upon are not captured. In addition, the overall patient population was generally low risk, with an average age of 62,
1. Gruntzig AR. Transluminal dilatation of coronary-artery stenosis. Lancet 1978;1:263.
2. Gruntzig AR, Senning A, Siegenthaler WE. Nonoperative dilatation of coronary-artery stenosis: Percutaneous transluminal coronary angioplasty. N Engl J Med 1979;301:61–68.
3. Sigwart U, et al. Intravascular stents to prevent occlusion and restenosis after transluminal angioplasty. N Engl J Med 1987;316:701–706.
4. Ritchie JL, et al. Coronary artery stent outcomes in a Medicare population: Less emergency bypass surgery and lower mortality rates in patients with stents. Am Heart J 1999;138:437–440.
5. Fischman DL, et al. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. Stent Restenosis Study Investigators. N Engl J Med 1994;331:496–501.
6. Serruys PW, et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. Benestent Study Group. N Engl J Med 1994;331:489–495.
7. de Jaegere PP, et al. Clinical trials on intracoronary stenting. Seminars in Interventional Cardiology 1996;1:233–245.
8. Peterson ED, et al. Evolving trends in interventional device use and outcomes: Results from the National Cardiovascular Network Database. Am Heart J 2000;139:198–207.
9. Peterson ED, et al. Acute and long-term cost implications of coronary stenting. J Am Coll Cardiol 1999;33:1610–1618.
10. Cantor WJ, et al. Achieving optimal results with standard balloon angioplasty: can baseline and angiographic variables predict stent-like outcomes? J Am Coll Cardiol 2001;37:1883–1890.
11. Cantor WJ, et al. Provisional stenting strategies: systematic overview and implications for clinical decision-making. J Am Coll Cardiol 2000;36:1142–1151.
12. Morice MC, et al. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 2002;346:1773–1780.
13. Park SJ, et al. A paclitaxel-eluting stent for the prevention of coronary restenosis. N Engl J Med 2003;348:1537–1545.
14. Moses JW, et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 2003;349:1315–1323.
15. Lemos PA, Serruys PW, Sousa JE. Drug-eluting stents: Cost versus clinical benefit. Circulation 2003;107:3003–3007.
16. Greenberg D, Cohen DJ. Examining the economic impact of restenosis: implications for the cost-effectiveness of an antiproliferative stent. Zeitschrift fur Kardiologie 2002;91(Suppl 3):137–143.
17. Mehta H, Hotz R, Windecker S, et al. Influence of frequency of stenting on acute and one-year follow-up results. J Invas Cardiol 2003;15:630–633.
