Coronary artery stenting: indications and cost implications.
The practice of coronary stenting is evolving rapidly, with new stent designs, deployment techniques, and adjunctive therapy. In many respects, clinical practice is changing in advance of the availability of supporting data. The consistent excellent angiographic result with stent deployment exceeds that achieved by any other previous interventional device, and the extent to which this accounts for the exponential increase in stent utilization cannot be accurately determined but is undoubtedly considerable. Controlled randomized trials have confirmed that stent deployment is superior to balloon angioplasty in certain lesion subsets or clinical scenarios. These include focal de novo native vessel lesions, lesions with late recoil after balloon angioplasty, acute closure after balloon angioplasty, and proximal left anterior descending coronary artery lesions. In addition, observational data is persuasive in focal coronary saphenous vein graft lesions and aorto-ostial lesions. On the other hand, the evidence supporting the use of stents strictly to improve on a suboptimal result, possibly the most frequent indication, is indirect and circumstantial. Stents are expensive, but it was anticipated that with the reduction in restenosis not only would they be cost-effective but also ultimately would reduce costs. This hope has not as yet been realized. However, there is little question that the introduction of intracoronary stents has been the most significant and exciting development since the introduction of percutaneous revascularization almost 20 years ago. It has revitalized the field.
Cohen
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EA
Sunnybrook Health Science Centre and The Toronto Hospital, University of Toronto, Canada.
Schwartz
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L
D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography; D003327:Coronary Disease / Q000000981:diagnostic imaging / Q000601:surgery*; D003363:Cost Control; D003362:Cost-Benefit Analysis; D004867:Equipment Design; D006801:Humans; D018579:Patient Selection; D012008:Recurrence; D015607:Stents / Q000191:economics / Q000592:standards*; D016896:Treatment Outcome