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Aetna Aetna
Clinical Policy Bulletin:
Drug-Eluting Stents
Number: 0621


Policy

  1. Aetna considers Food and Drug Administration (FDA)-approved everolimus-eluting stents, paclitaxel-eluting stents, sirolimus-eluting stents, and zotarolimus-eluting stents medically necessary for members with angina pectoris or silent ischemia and greater than 50 % stenosis of one or more coronary arteries.

  2. Aetna considers drug-eluting stents experimental and investigational for treatment of all other indications, including any of the following because their effectiveness for these indications has not been established:
     
    • Aorto-arteritis (also known as Takayasu arteritis); or
    • Non-malignant gastric outlet obstruction; or
    • Pancreato-biliary diseases such as bile duct obstruction (including their use in endoscopic retrograde cholangiopancreatography); or
    • Stenotic lesions of non-coronary arteries (e.g., peripheral vascular disease, renal artery stenosis); or
    • Vein graft stenosis; or
    • Venous stenosis associated with dialysis vascular access
       
  3. Aetna considers biodegradable (bioresorbable, bioabsorbable) polymer drug eluting stents experimental and investigational because their effectiveness for these indications has not been established.

See also CPB 0785 - Peripheral Vascular Stents.



Background

This policy is consistent with the Food and Drug Administration (FDA)-approved indications for sirolimus-eluting stents (Rx Velocity, Cordis, Johnson & Johnson) and paclitaxel-eluting stents (Taxus Express, Boston Scientific Corporation).

The use of stents has improved the results of percutaneous coronary re-vascularization.  However, in-stent restenosis due to neointimal proliferation of connective tissue has been reported to occur in approximately 15 to 20 % of stent patients.

The macrolide anti-fungal agent sirolimus (rapamycin) has been shown to inhibit the proliferation of lymphocytes and smooth muscle cells and has been applied to the interior of balloon-expandable stents.  The Rx Velocity consists of a stent coated with a mixture of synthetic polymers blended with sirolimus.  The Rx Velocity is designed to release 80 % of the drug within 30 days after stent implantation.  Only a small amount of the drug is required, and systemic side effects from the drug are avoided.

The FDA approved the stent based on a review of 2 clinical studies of safety and effectiveness of the sirolimus-eluting stent.  In a multi-center, randomized, double-blind, controlled clinical trial conducted in the United States (the SIRIUS study), 1,058 patients were randomly assigned to receive either the sirolimus-eluting stent or an uncoated stainless steel stent.  Patients in the SIRIUS study had blockages of 15 mm to 30 mm long in arteries that were 2.5 mm to 3.5 mm wide.

Results were similar for both types of stents in the weeks immediately following the procedure, but after 9 months the patients who received the drug-eluting stent had a significantly lower rate of repeat procedures than patients who received the uncoated stent (4.2 % versus 16.8 %).  In addition, patients treated with the drug-eluting stent had a re-stenosis rate of 8.9 %, compared to 36.3 % of patients with the uncoated stent.  The combined occurrence of repeat angioplasty, bypass surgery, myocardial infarction and death was 8.8 % for drug-eluting stent patients and 21 % for the uncoated stent patients.  The types of adverse events seen with the drug-eluting stent were similar to those that occurred with the uncoated stent.

The FDA's approval of the sirolimus-eluting stent was also based on the results of a non-U.S. multi-center, randomized, double-blind, controlled clinical trial (the RAVEL study) comparing sirolimus-eluting stents with standard uncoated stents in 238 adults with stable or unstable angina pectoris or silent ischemia and single coronary lesions amenable to stenting.  Lesions had to be between 2.5 mm and 3.5 mm in diameter, such that they could be covered by an 18 mm stent.  Patients with complex coronary lesions, such as those containing substantial calcium or thrombus, were excluded from the study.

The investigators reported that use of a sirolimus-eluting stent resulted in the virtual elimination of angiographic evidence of neointimal hyperplasia and re-stenosis and greatly reduced the need for repeated re-vascularization procedures.  At 6 months after stent placement, there was significantly less in-stent late luminal loss (a measure of neointimal proliferation) in patients receiving sirolimus-eluting stents than in patients receiving standard, uncoated stents.  None of the patients receiving sirolimus-eluting stents had restenosis of 50 % or more of the luminal diameter, compared to 26.6 % of patients receiving standard stents.  Within 1 year following stent placement, percutaneous re-vascularization had been performed in 22.9 % of recipients of standard, uncoated stents, and in none of the recipients of sirolimus-eluting stents.  The investigators concluded that angina patients who received sirolimus-eluting stents had no angiographic evidence of late luminal loss or in-stent restenosis at 6 months after sirolimus-eluting stent placement and a very low rate of cardiovascular events within the year following stenting.

The safety and effectiveness of the Cypher stent in smaller diameter arteries or for longer blockage that required more than 2 stents was not studied in either trial.  Also, the safety and effectiveness have not been studied in patients who are having a heart attack, patients who had previous intravascular radiation treatment, or patients who had their blockage in a bypass graft.

The FDA-approved labeling of the sirolimus-eluting stent warns that patients who are allergic to sirolimus or to stainless steel should not receive a Cypher stent.  Caution is also recommended for people who have had recent cardiac surgery and for women who may be pregnant or who are nursing.

The FDA is requiring the manufacturer of the sirolimus-eluting stent to conduct a 2,000-patient post-approval study and continue to evaluate patients from ongoing clinical trials to assess the long-term safety and effectiveness of the sirolimus-eluting stent and to look for rare adverse events that may result from the use of this product.

The FDA has approved the paclitaxel-eluting stents (Taxus Express Paclitaxel-Eluting Coronary Stent System, Boston Scientific Corporation) for improving luminal diameter for the treatment of de novo lesions less than 28 mm in length in native coronary arteries greater than or equal to 2.5 to less than or equal to 3.75 mm in diameter.  Paclitaxel (Taxol) is similar to sirolimus in that it has been shown to inhibit proliferation of connective tissues and smooth muscle.

Stone et al (2004) reported on the results of the Taxus-IV trial, a multi-center prospective, randomized, double-blind controlled clinical trial of a paclitaxel-eluting stent in 1,314 patients with angina or provokable ischemia who were receiving a stent in a single, previously untreated lesion in a native coronary artery.  Patients in the Taxus-IV trial had vessel diameters between 2.5 and 3.75 mm, and had lesions between 10 to 28 mm in length that could be covered by a single stent.  Patients with lesions of the left-main coronary artery were excluded.  Patients were randomly assigned to receive either a bare-metal stent (BMS) or a paclitaxel-eluting stent (PES).  At 9 months follow-up, the rate of target vessel re-vascularization due to ischemia was 12 % in patients who received the BMS, and 4.7 % in patients who received the PES (relative risk [RR] 0.39 (95 % confidence interval [CI]: 0.16 to 0.43).  The rate of angiographic restenosis was 26.6 % in patients who received the BMS, and 7.9 % in patients who received the PES (RR 0.30 (95 % CI: 0.19 to 0.46).  The rates of adverse events were similar between patients receiving the PES and the BMS.

The safety and effectiveness of the Taxus Express stent in smaller diameter arteries or for longer blockage that required more than 2 stents has not been studied.  Also, the safety and effectiveness have not been studied in patients who are having a myocardial infarction, patients who had previous intravascular brachytherapy, or patients who had stenosis of a bypass graft.

The FDA-approved labeling of the PES warns that patients who are allergic to paclitaxel or to stainless steel should not receive a Taxus Express stent.  Caution is also recommended for people who have had recent cardiac surgery and for women who may be pregnant or who are nursing.

The FDA is requiring the manufacturer of the PES to conduct a 2,000 patient post-approval study and continue to evaluate patients from ongoing clinical trials to assess the long-term safety and effectiveness of the PES and to look for rare adverse events that may result from the use of this product.

In a randomized controlled trial (n = 57), Duda et al (2005) examined the safety and effectiveness of the sirolimus-eluting S.M.A.R.T. Nitinol Self-expanding Stent by comparison with a bare stent in superficial femoral artery (SFA) obstructions.  These investigators concluded that although there is a trend for greater efficacy in the sirolimus-eluting stent group, there were no statistically significant differences in any of the variables.

In a recent review on advances in the medical and surgical treatment of aorto-arteritis (also known as Takayasu arteritis), an inflammatory vascular disorder that produces arterial stenoses and aneurysms primarily involving the thoraco-abdominal aorta and its branches and the pulmonary arteries, Liang and Hoffman (2005) stated that new drugs that target intimal hyperplasia, as well as drug-eluting stents, deserve to be studied for possible utility as adjuncts to present treatments.

Dzavik (2005) stated that bifurcation lesions have been recognized as one of the most important challenges facing interventional cardiologists since the start of percutaneous coronary intervention (PCI).  The potential of peri-procedural occlusion of the side branch (SB) was found to be significant, resulting in early attempts at protecting the SB with a 2nd guide wire and kissing balloon inflation in order to minimize this risk, and thus improve the procedural and short-term success of the procedure.  The advent of stenting significantly improved the safety of the procedure, although, SB success continued to be a challenge.  A variety of single- as well as double-stenting techniques were developed that improved the safety and short-term results of PCI involving SB.  Long-term success, however, continued to elude, as a consequence of an increased need for target lesion revascularization (TLR) and higher major adverse cardiac event (MACE) rates following PCI of bifurcation lesions.  The introduction of drug-eluting stents appears to have brought bifurcation PCI to a new level of long-term efficacy.  Specialty bifurcation stents have been developed to provide easy access to the SB, however, these have to date had little impact on practice and have not been adopted widely.  New techniques such as crush stenting and its several permutations, and simultaneous kissing stenting developed specifically for drug-eluting stents have been developed.  Debate continues as to which the most effective technique is.  True randomized comparisons are, however, lacking.  It is likely that all of the currently utilized techniques have a place in interventional cardiologists’ quiver, and that each is appropriate in a particular anatomical scenario.  Nonetheless, well-designed randomized studies assessing the various bifurcation techniques especially in complex bifurcation lesions are needed.  Moreover, Iakovou et al (2005) reported that the cumulative incidence of stent thrombosis 9 months after successful drug-eluting stent implantation in consecutive "real-world" patients was substantially higher than the rate reported in clinical trials.  Premature anti-platelet therapy discontinuation, renal failure, bifurcation lesions, diabetes, and low ejection fraction were identified as predictors of thrombotic events.

Shammas and Dippel (2005) stated that peripheral vascular disease (PVD) is very prevalent in the United States.  Patients with PVD have a heightened inflammatory state and are at high-risk of death from acute cardiovascular problems rather than from progression of PVD.  Modifiable risk factors for PVD include smoking, hypertension, diabetes, hyperlipidemia, elevated high sensitivity C-reactive protein, obesity, and the metabolic syndrome.  Symptomatic treatment of claudication includes smoking cessation, exercise, cilostazol, statins, and re-vascularization with percutaneous or surgical therapy.  Anti-thrombotic therapy with aspirin or clopidogrel is important to reduce cardiovascular events but does not affect symptoms of claudication.  Patients with rest limb ischemia or ulceration should be re-vascularized to minimize the chance of limb loss.  Percutaneous re-vascularization is not without significant complications, however, and future research needs to focus on inflammation, thrombosis, and restenosis in the PVD patient.  Furthermore, new devices that tackle difficult lesions, drug-eluting stents, and pharmacological agents that reduce global atherosclerosis are on the horizon, and are likely to become critical components in the management of the PVD patient.

Owens et al (2011) stated that the endovascular management of symptomatic atherosclerotic SFA disease is challenging and requires consideration of unique anatomical, hemodynamic, and biomechanical factors.  The current armamentarium of balloon catheters and flexible nitinol BMS have limited long-term effectiveness due to intimal hyperplasia resulting in re-stenosis.  Unfortunately, the remarkably low re-stenosis rates achieved with drug-eluting stents (DES) placed in the coronary vasculature has not been replicated in the femoral artery.  The reason for this is multi-factorial including delivery platforms, drug and dosage selection and trial design flaws.  Currently, however, there are several novel therapies and delivery platforms in the development pipeline that have exhibited biologic effectiveness in pre-clinical and early clinical trials.  While these offer promise in improving outcomes following lower extremity intervention, caution is warranted until the safety of these new technologies can be ensured.

Henry et al (2005) stated that percutaneous angioplasty and stent placement seem a useful technique for the treatment of vertebro-basilar insufficiency.  This technique appears safe and effective for alleviating symptoms and improving blood flow to the cerebral circulation, with a low complications rate and good long-term results.  However, this procedure needs experienced interventionists to choose the stent and have appropriate placement of the stent in the ostium of the vertebral artery (VA).  The tortuosity of the VA may be technically challenging.  The new coronary stents seem to be well-suited to treat atherosclerotic lesions of the origin and of the proximal VA.  A large variability of restenosis risk has been reported.  Drug-eluting stents may be the solution.  The authors stated that prospective, randomized trials are needed to ascertain the clinical effectiveness of VA stenting in stroke prevention, its durability, and to define more clearly its indications.

Vermeersch and Agostoni (2005) noted that the percutaneous treatment of patients with obstructive atherosclerotic disease in degenerated coronary saphenous vein bypass grafts still remains one of the great challenges in interventional cardiology.  These researchers discussed the actual evidence-based knowledge for the percutaneous management of this lesion subset, focusing in particular on the devices that are actually considered the "gold standard" for this treatment: BMS and distal protection devices.  They commented on the negative results of the randomized trials regarding the promising polytetrafluoroethylene-covered stent-grafts, and offered insights into the currently available evidence for the use of DES in saphenous vein grafts.  The authors stated that these devices are potentially the key promise for the long-term successful sealing of vein graft disease; however, clear and definitive data from controlled studies are needed.

Kolluri et al (2006) noted that renal artery stenosis (RAS) is a progressive manifestation of atherosclerosis.  It is associated with hypertension and progressive renal failure.  Non-invasive testing includes renal artery duplex, computed tomographic angiography and magnetic resonance angiography.  Percutaneous transluminal renal angioplasty and stenting (PTRAS) is indicated for significant atherosclerotic RAS while percutaneous transluminal renal angioplasty is indicated for fibromuscular dysplasias associated with the proper clinical indications.  PTRAS is associated with a high technical success rate and an acceptable adverse event and restenosis rate.  Moreover, PTRAS appears to improve control of hypertension and renal preservation.  All patients should be followed clinically and with periodic duplex ultrasonography.  Re-stenosis is treated with repeat angioplasty and occasionally stenting.  Current and future areas of investigation will involve distal protection and DES.

At the 2006 European Society/World Congress of Cardiology, results of 3 studies suggested that DES may lead to an increased risk of death and cardiac events compared with BMS.  One study suggested an increase in death and Q-wave myocardial infarction (MI) in subjects receiving a sirolimus-eluting stent, while the other indicated that this type of DES might increase non-cardiac mortality.

In the first study, Camenzind and associates performed a meta-analysis on randomized clinical studies comparing 1st-generation DES with BMS.  Sirolimus-eluting stent trials entailed the RAVEL, SIRIUS, E-SIRIUS, and C-SIRIUS, and included 878 patients fitted with the novel stent and 870 who received BMS.  The PES trials entailed TAXUS II, IV, V, and VI, and included information on 1,685 patients fitted with this stent and 1,675 who received BMS.  The pooled incidence of death and Q-wave MI combined, analyzed from within the program by time points of follow-up, was significantly higher with the sirolimus-eluting stent than the BMS at 3 years, at 6 % versus 4 %, representing a 33 % relative increase in risk.  In PES trials, the incidence of the combined endpoint at 3 years was 3.5 % with the DES compared with 3.1 % for the BMS.  Pooling the latest follow-up data from each trial program revealed that the incidence all-cause death or MI was 2.4 % higher with the sirolimus-eluting stent than the BMS (6.3 % versus 3.9 %) and 0.3 % higher for PES than the BMS (2.6 % versus 2.3 %).  Further analysis indicated that the rate of total mortality and Q-wave MI combined was a significant 38 % higher with the sirolimus-eluting stent versus the BMS (p = 0.03), while there was a trend towards a 16 % higher incidence with the PES.  These researchers warned against indiscriminate use of 1st-generation DES and said that use of BMS may still be maintained, while awaiting safer 2nd-generation DES.

In the second study, Nordmann et al conducted a meta-analysis of randomized controlled trials that compared sirolimus-eluting stents and PES with BMS in their effect on total, cardiac, and non-cardiac mortality using last follow-up data.  They found that although there was a trend to benefits with the DES for reducing total mortality at 1 year compared with BMS, there was a trend to increased mortality in years 2, 3, and 4 of follow-up.  Furthermore, at 2 and 3 years' follow-up, there was increased non-cardiac mortality (cancer, lung disease, and stroke) with the sirolimus-eluting stent versus the BMS (odds ratio = 2.74 and 2.04, respectively), the majority of which related to cancer.  These investigators concluded that preliminary evidence suggests that sirolimus-eluting stents but not PES may lead to increased non-cardiac mortality.  Follow-up and assessment of cause-specific deaths in patients receiving DES are mandatory to determine the safety of these devices.

A third study tracked stent thrombosis rates in 8,000-plus patients enrolled in studies in Holland and Switzerland. Wenaweser reported that over 3 years, the cumulative rate of thrombosis was 2.9 %, but what was disturbing was that the rate was linear -- starting at 1.2 % at 30 days (similar to BMS) and then 0.6 % each year thereafter.  Unlike BMS, thrombosis did not seem to wane with time, but continued to increase at the same rate, confirming concerns that DES suppress cell growth too much in some individuals, opening the door to thrombosis, which have serious consequences.

In the light of ongoing concerns over the safety of DES, the Society for Cardiovascular Angiography and Interventions (SCAI) has issued guidelines for use of the devices (Hodgson et al, 2007).  The guidelines advise physicians to ensure that patients meet published guidelines' criteria for percutaneous coronary intervention before implantation of any stent.  The guidelines also recommend that the physician decide on an individual-patient basis whether a DES, BMS, or surgical revascularization is most appropriate; discuss the risks and benefits with the patient; and document it in the medical record.  The guidelines recommend that providers know which patients (those with diabetes, renal failure, etc.) and lesions (complex, long, small-diameter, etc.) carry high-risk for thrombosis with DES.  Ideally, physicians should assess patients' likelihood of long-term compliance with dual antiplatelet therapy before implantation.  Continuation for 1 year is strongly recommended in patients not at high risk for bleeding, and continuation beyond 1 year should be considered in patients at higher risk for stent thrombosis.

Tu and colleagues (2007) stated that the placement of DES decreases the frequency of repeat re-vascularization procedures in patients undergoing PCI in randomized clinical trials.  However, there is uncertainty about the effectiveness of DES, and increasing concern about their safety, in routine clinical practice.  From the Cardiac Care Network of Ontario's population-based clinical registry of all patients undergoing PCI in Ontario, Canada, these investigators identified a well-balanced cohort of 3,751 pairs of patients, matched on the basis of propensity score, who received either BMS alone or DES alone during an index PCI procedure between December 1, 2003, and March 31, 2005.  The primary outcomes of the study were the rates of target-vessel re-vascularization, MI, and death.  The 2-year rate of target-vessel re-vascularization was significantly lower among patients who received DES than among those who received BMS (7.4 % versus 10.7 %, p < 0.001).  Drug-eluting stents were associated with significant reductions in the rate of target-vessel re-vascularization among patients with 2 or 3 risk factors for re-stenosis (i.e., presence of diabetes, small vessels [less than 3 mm in diameter], and long lesions [greater than or equal to 20 mm]) but not among lower-risk patients.  The 3-year mortality rate was significantly higher in the BMS group than in the DES group (7.8 % versus 5.5 %, p < 0.001), whereas the 2-year rate of MI was similar in the 2 groups (5.2 % and 5.7 %, respectively; p = 0.95).  The authors concluded that DES are effective in reducing the need for target-vessel re-vascularization in patients at highest risk for re-stenosis, without a significantly increased rate of death or MI.

In a meta-analysis, Stettler et al (2007) compared the safety and effectiveness of 2 DES (sirolimus-eluting stent and PES) and BMS.  These investigators searched relevant sources from inception to March, 2007, and contacted investigators and manufacturers to identify randomized controlled trials in patients with coronary artery disease that compared DES with BMS, or that compared sirolimus-eluting stents head-to-head with PES.  Safety outcomes included mortality, MI, and definite stent thrombosis; the effectiveness outcome was target lesion re-vascularization.  These researchers included 38 trials (18,023 patients) with a follow-up of up to 4 years.  Trialists and manufacturers provided additional data on clinical outcomes for 29 trials.  A network meta-analysis with a mixed-treatment comparison method to combine direct within-trial comparisons between stents with indirect evidence from other trials while maintaining randomization was performed.  Mortality was similar in the 3 groups: hazard ratios (HR) were 1.00 (95 % CI: 0.82 to 1.25) for sirolimus-eluting versus BMS, 1.03 (0.84 to 1.22) for PES versus BMS, and 0.96 (0.83 to 1.24) for sirolimus-eluting versus PES.  Sirolimus-eluting stents were associated with the lowest risk of MI (HR 0.81, 95 % CI: 0.66 to 0.97, p = 0.030 versus BMS; 0.83, 0.71 to 1.00, p = 0.045 versus PES).  There were no significant differences in the risk of definite stent thrombosis (0 days to 4 years).  However, the risk of late definite stent thrombosis (greater than 30 days) was increased with PES (HR 2.11, 95 % CI: 1.19 to 4.23, p = 0.017 versus BMS; 1.85, 1.02 to 3.85, p = 0.041 versus sirolimus-eluting stents).  The reduction in target lesion re-vascularization seen with DES compared with BMS was more pronounced with sirolimus-eluting stents than with PES (0.70, 0.56 to 0.84; p = 0.0021).  The authors concluded that the risks of mortality associated with DES and BMS are similar.  Sirolimus-eluting stents seem to be clinically better than BMS and PES.

In a meta-analysis, Schomig et al (2007) made a synthesis of the available evidence on the relative safety and effectiveness of 2 DES: (i) sirolimus-eluting stents (SES) and (ii) PES in patients with coronary artery disease.  A total of 16 randomized trials of SES versus PES with a total number of 8,695 patients were included in this analysis.  A full set of individual outcome data from 5,562 patients was also available.  Mean follow-up period ranged from 9 to 37 months.  The primary effectiveness end point was the need for re-intervention (target lesion re-vasculization).  The primary safety end point was stent thrombosis.  Secondary end points were death and recurrent MI.  No significant heterogeneity was found across trials.  Compared with PES, SES significantly reduced the risk of re-intervention (HR 0.74; 95 % CI: 0.63 to 0.87, p < 0.001) and stent thrombosis (HR 0.66; 95 % CI: 0.46 to 0.94, p = 0.02) without significantly impacting on the risk of death (HR 0.92; 95 % CI: 0.74 to 1.13, p = 0.43) or MI (HR 0.84; 95 % CI: 0.69 to 1.03, p = 0.10).  The authors concluded that SES are superior to PES in terms of a significant reduction of the risk of re-intervention and stent thrombosis.  The risk of death was not significantly different between the 2 DES, but there was a trend toward a higher risk of MI with PES, especially after the first year from the procedure.  The observation that SES are superior to PES is in agreement with the analysis from Gurm et al (2008) who reported that patients treated with SES appear to have a significantly lower risk of re-stenosis and need for target vessel re-vascularization compared with those treated with PES.

The National Institute for Health and Clinical Excellence's (NICE, 2008) recommended the use of DES for the treatment of coronary artery disease only if the target artery to be treated has less than a 3-mm caliber or the lesion is longer than 15 mm, and the price difference between DES and BMS is no more than 300 pounds sterling.

Pfisterer et al (2009) evaluated the long-term benefit-risk ratio of DES versus BMS relative to stent size.  All 826 consecutive BASKET (BAsel Stent Kosten-Effektivitäts Trial) patients randomized 2:1 to DES versus BMS were followed after 3 years.  Data were analyzed separately for patients with small stents (less than 3.0 mm vessel/less than 4.0 mm bypass grafts, n = 268) versus only large stents (greater than or equal to 3.0 mm native vessels, n = 558).  Clinical events were related to stent thrombosis.  Three-year clinical target vessel revascularization (TVR) rates remained borderline reduced after DES [9.9 versus 13.9 % (BMS), p = 0.07], particularly in patients with small stents (10.7 versus 19.8 %, p = 0.03; large stents: 9.5 versus 11.5 %, p = 0.44).  Cardiac death/MI rates (12.7 versus 10.0 %, p = 0.30) were similar, however, death/MI beyond 6 months was higher after DES [9.1 versus 3.8 % BMS, p = 0.009], mainly due to increased late death/MI in patients with large stents (9.7 versus 3.1 %, p = 0.006).  The results paralleled findings for stent thrombosis.  The authors concluded that the clinical benefit of DES was maintained at no overall increased risk of death or death/MI up to 3 years.  However, death/MI rates were increased in DES versus BMS patients beyond 6 months, especially in patients with large stents, paralleling findings for stent thrombosis.  Thus, stent size appears to influence the 3-year benefit-risk ratio after DES implantation.

Kirtane and colleagues (2009) performed a meta-analysis of DES studies to estimate the relative impact of DES versus BMS on safety and efficacy end points, particularly for non-FDA-labeled indications.  Comparative DES versus BMS studies published or presented through February 2008 with greater than or equal to 100 total patients and reporting mortality data with cumulative follow-up of greater than or equal to 1 year were identified.  Data were abstracted from studies comparing DES with BMS; original source data were used when available.  Data from 9,470 patients in 22 randomized controlled trials (RCTs) and from 182,901 patients in 34 observational studies were included.  Observational and RCT data were analyzed separately.  In RCTs, DES (compared with BMS) were associated with no detectable differences in overall mortality (HR, 0.97; 95 % CI: 0.81 to 1.15; p = 0.72) or MI (HR, 0.95; 95 % CI: 0.79 to 1.13; p = 0.54), with a significant 55 % reduction in target vessel re-vascularization (HR, 0.45; 95 % CI: 0.37 to 0.54; p < 0.0001); point estimates were slightly lower in off-label compared with on-label analyses. In observational studies, DES were associated with significant reductions in mortality (HR, 0.78; 95 % CI: 0.71 to 0.86), MI (HR, 0.87; 95 % CI: 0.78 to 0.97), and TVR (HR, 0.54; 95 % CI: 0.48 to 0.61) compared with BMS.  The authors concluded that in RCTs, no significant differences were observed in the long-term rates of death or MI after DES or BMS use for either off-label or on-label indications.  In real-world non-randomized observational studies with greater numbers of patients but the admitted potential for selection bias and residual confounding, DES use was associated with reduced death and MI.  Both RCTs and observational studies demonstrated marked and comparable reductions in target vessel re-vascularization with DES compared with BMS.  These data in aggregate suggested that DES are safe and efficacious in both on-label and off-label use, but highlighted differences between RCT and observational data comparing DES and BMS.

In a systematic review and meta-analysis, Brar et al (2009) compared outcomes by stent type for death, MI, TVR, and stent thrombosis in RCTs of ST-segment elevation myocardial infarction (STEMI).  A secondary analysis was performed among registry studies.  These investigators searched Medline, Embase, the Cochrane Library, and Internet sources for articles comparing outcomes between DES and BMS among patients with STEMI between January 2000 and October 2008.  Randomized controlled trials and registries including patients 18 years of age and older receiving a DES or BMS were included.  These researchers extracted variables related to the study design, setting, participants, and clinical end points.  A total of 13 RCTs were identified (n = 7,352).  Compared with BMS, DES significantly reduced TVR (relative risk [RR]: 0.44; 95 % CI: 0.35 to 0.55), without increasing death (RR: 0.89; 95 % CI: 0.70 to 1.14), MI (RR: 0.82; 95 % CI: 0.64 to 1.05), or stent thrombosis (RR: 0.97; 95 % CI: 0.73 to 1.28).  These observations were durable over 2 years.  Among 18 registries (n = 26,521), DES significantly reduced TVR (RR: 0.54; 95 % CI: 0.40 to 0.74) without an increase in MI (RR: 0.87, 95 % CI: 0.62 to 1.23).  Death was significantly lower in the DES group within 1 year of the index PCI, but there were no differences within 2 years (p = 0.45).  The authors concluded that the use of DES appears safe and efficacious in RCTs and registries of patients with STEMI.  The DES significantly reduce TVR compared with BMS, without an increase in death, MI, or stent thrombosis within 2 years of the index procedure.

Trikalinos and associates (2009) noted that over the past 2 decades, percutaneous transluminal balloon coronary angioplasty (PTCA), BMS, and DES succeeded each other as catheter-based treatments for coronary artery disease.  These researchers carried out a systematic overview of RCTs comparing these interventions with each other and with medical therapy in patients with non-acute coronary artery disease.  They searched Medline for trials contrasting at least 2 of the 4 interventions (PTCA, BMS, DES, and medical therapy).  Eligible outcomes were death, MI, coronary artery bypass grafting, TLR/TVR, and any re-vascularisation.  Random effects meta-analyses summarized head-to-head (direct) comparisons, and network meta-analyses integrated direct and indirect evidence.  A total of 61 eligible trials (25,388 patients) investigated 4 of 6 possible comparisons between the 4 interventions; no trials directly compared DES with medical therapy or PTCA.  In all direct or indirect comparisons, succeeding advancements in PCI did not produce detectable improvements in deaths or MI.  The RR for indirect comparisons between DES and medical therapy was 0.96 (95 % CI: 0.60 to 1.52) for death and 1.15 (0.73 to 1.82) for MI.  By contrast, these investigators recorded sequential significant reductions in target lesion or vessel re-vascularisation with BMS compared with PTCA (RR 0.68 [0.60 to 0.77]) and with DES compared with BMS (0.44 [0.35 to 0.56]).  The RR for the indirect comparison between DES and PTCA for TLR/TVR was 0.30 (0.17 to 0.51).  The authors concluded that sequential innovations in the catheter-based treatment of non-acute coronary artery disease showed no evidence of an effect on death or MI when compared with medical therapy.  These results lend support to present recommendations to optimize medical therapy as an initial management strategy in patients with this disease.

Biondi-Zoccai et al (2008) conducted a systematic review of basic science and clinical evidence on the Xience V everolimus-eluting stents (EES), by thoroughly searching PubMed and online databases (updated September 2007).  They also compared the clinical results of Xience V versus PES (Taxus) and SES (Cypher) by means of direct and indirect comparison meta-analysis.  A total of 3 clinical studies has been retrieved focusing on Xience V, however both most recent and important trials were still unpublished.  The first trial compared Xience V versus BMS, whereas the other 2 RCTs compared Xience V versus Taxus.  Direct meta-analysis of Xience V versus Taxus showed that Xience V was significantly superior to Taxus in preventing binary angiographic re-stenosis and TVR (p < 0.05 for both).  Indirect comparison between Xience V and Cypher, exploiting a recent 16-trial large meta-analysis, showed that Xience V was at least as effective as Cypher in preventing TVR (p = 0.12).  The authors concluded that EES (Xience V) appear as a major breakthrough in coronary interventions, and superior efficacy has already been demonstrated in comparison to PES (Taxus).  Data available to date also suggested that Xience V is at least as effective as SES (Cypher).  Whether long-term results and direct comparison to Cypher will also be favorable remains to be established by future clinical trials.

Stone and colleagues (2009) reported the 2-year clinical follow-up data of EES in the treatment of patients with de novo native coronary artery lesions (SPIRIT) III trial.  A total of 1,002 patients with up to 2 de novo native coronary artery lesions (reference vessel diameter, 2.5 to 3.75 mm; lesion length less than or equal to 28 mm) were randomized 2:1 to EES versus PES.  Anti-platelet therapy consisted of aspirin indefinitely and a thienopyridine for greater than or equal to 6 months.  Between 1 and 2 years, patients treated with EES compared with PES tended to have fewer episodes of protocol-defined stent thrombosis (0.2 % versus 1.0 %; p = 0.10) and MI (0.5 % versus 1.7 %; p = 0.12), with similar rates of cardiac death (0.3 % versus 0.3 %; p = 1.0) and TVR (2.9 % versus 3.0 %; p = 1.0).  As a result, at the completion of the 2-year follow-up, treatment with EES compared with PES resulted in a significant 32 % reduction in target vessel failure (10.7 % versus 15.4 %; HR, 0.68; 95 % CI: 0.48 to 0.98; p = 0.04) and a 45 % reduction in major adverse cardiac events (cardiac death, MI, or target lesion revascularization; 7.3 % versus 12.8 %; hazard ratio, 0.55; 95 % CI: 0.36 to 0.83; p = 0.004).  Among the 360 patients who discontinued clopidogrel or ticlopidine after 6 months, stent thrombosis subsequently developed in 0.4 % of EES patients versus 2.6 % of PES patients (p = 0.10).  The authors concluded that patients treated with EES rather than PES experienced significantly improved event-free survival at a 2-year follow-up in the SPIRIT III trial, with continued divergence of the hazard curves for target vessel failure and major adverse cardiac events between 1 and 2 years evident.  The encouraging trends toward fewer stent thrombosis episodes after 6 months in EES-treated patients who discontinued a thienopyridine and after 1 year in all patients treated with EES rather than PES deserve further study.

Chevalier and associates (2008) compared zotarolimus-eluting stents (ZES) with PES in a randomized trial of percutaneous intervention for de novo coronary artery stenosis.  The primary end point was defined as non-inferiority of in-segment late lumen loss after 9 months.  A total of 29 investigative sites in Europe, Australia, as well as New Zealand enrolled 401 patients, 396 of whom received a study stent.  After 9 months, late lumen loss was significantly greater in the ZoMaxx group (in-stent 0.67 +/- 0.57 mm versus 0.45 +/- 0.48 mm; p < 0.001; in-segment 0.43 +/- 0.60 mm versus 0.25 +/- 0. 45 mm; p = 0.003), resulting in significantly higher rates of greater than 50 % angiographic re-stenosis (in-stent 12.9 % versus 5.7 %; p = 0.03; in-segment 16.5 % versus 6.9 %; p = 0.007).  The upper bound of the 95 % CI on the difference in in-segment late lumen loss between the 2 treatment groups (0.27 mm) exceeded the 0.25 mm value pre-specified for non-inferiority.  There were no significant differences between ZoMaxx and Taxus-treated groups with respect to TVR (8.0 % versus 4.1 %; p = 0.14), major adverse cardiac events (12.6 % versus 9.6 %; p = 0.43), or stent thrombosis (0.5 % in both groups).  The authors concluded that after 9 months, ZES showed less neointimal inhibition than PES, as shown by higher in-stent late loss and re-stenosis by qualitative coronary angiography.

Waseda and colleagues (2009) compared the vessel response between ZES and PES using intra-vascular ultrasound (IVUS).  Data were obtained from patients with serial (baseline and 8-months follow-up) IVUS analysis available (n = 198).  Volumetric analysis was performed for vessel, lumen, plaque, stent, and neointima.  Cross-sectional narrowing (given as percentage) was defined as neointimal area divided by stent area.  Neointima-free frame ratio was calculated as the number of frames without IVUS-detectable neointima divided by the total number of frames within the stent.  Subsegment analysis was performed at every matched 1-mm subsegment throughout the stent.  At follow-up, the ZES group showed significantly greater percentage of neointimal obstruction (16.6 +/- 12.0 % versus 9.9 +/- 8.9 %, p < 0.01) and maximum cross-sectional narrowing (31.8 +/- 16.1 % versus 25.2 +/- 14.9 %, p < 0.01) with smaller minimum lumen area than the PES group did.  However, the incidence of maximum cross-sectional narrowing greater than 50 % was similar in the 2 groups.  Neointima-free frame ratio was significantly lower in the ZES group.  In overall analysis, whereas the PES group showed positive remodeling during follow-up (13.7 +/- 4.2 mm(3)/mm to 14.3 +/- 4.3 mm(3)/mm), the ZES group showed no significant difference (12.7 +/- 3.6 mm(3)/mm to 12.9 +/- 3.5 mm(3)/mm). In subsegment analysis, significant focal positive vessel remodeling was observed in 5 % of ZES and 25 % of PES cases (p < 0.05).  The authors concluded that there were different global and focal vessel responses for ZES and PES.  Both DES showed a similar incidence of lesions with severe narrowing despite ZES having a moderate increase in neointimal hyperplasia compared with neointimal hyperplasia in PES.  There was a relatively lower neointima-free frame ratio in ZES, suggesting a greater extent of neointimal coverage.

The Endeavor ZES from Medtronic received FDA approval on February 1, 2008, while Xience V EES from Abbott Vascular was approved by FDA on July 2, 2008 (Doostzadeh et al, 2010).

Machan (2006) reviewed the use of DES outside the coronary artery.   The majority of research and clinical data on DES are from their use in coronary artery atherosclerosis; however, these devices can be used outside the coronary circulation in both vascular and non-vascular structures.  In non-coronary arteries the principal indication for DES is the same as in the coronary circulation, prevention of re-stenosis.  Human experience has been essentially limited to trials or compassionate use; 2 small controlled studies and a number of small observational single-center reports have been published, and there are trials in progress.  To date, the data have not been as compelling as in the coronary circulation.  The physical characteristics of each vascular bed such as external compressive forces, blood flow rates, wall thickness relative to lumen size, as well as vessel wall composition differ significantly from the coronary circulation and each presents unique challenges to local drug delivery.  Outside the vascular bed, the principal expected use is the prevention of tissue ingrowth following stent insertion in tubular structures such as the trachea, esophagus or bile ducts.  The authors concluded that considerable further study of DES is needed in each anatomical region to determine the ideal stent/drug combination and clinical appropriateness.

Lee (2009) noted that in unresectable malignant bile duct obstruction, endoscopic stent insertion is the treatment of choice.  However, the current stent allows only mechanical palliation of the obstruction, and has no anti-tumor effect.  Currently, in the vascular field, the DES is very highly favored.  The requirements for a DES in a non-vascular tract, such as the bile duct, are far different from those of a DES to be used in the vascular tract.  The non-vascular DES must suppress tumor proliferation and mucosal hyperplasia.  For example, the non-vascular stent might be covered with a membrane that gradually releases a chemo-agent.  Currently, there is not much experience with DES in the bile duct.  Nevertheless, these researchers are continuously testing many anti-tumor agents in animal and human studies.  The authors concluded that they expect and hope DES will work effectively for tumor cells in diverse ways and, more importantly, will prolong stent patency and the patients' survival periods.  However, considerable investigation and a clinical study of DES will be required to achieve these goals.

In a meta-analysis, Joyal et al (2010) compared DES to BMS for the treatment of vein graft stenosis.  PubMed and the Cochrane clinical trials database were systematically searched to identify all RCTs and observational studies examining DES for vein graft stenosis published in English between 2003 and 2009.  Inclusion criteria included follow-up duration greater than or equal to 6 months.  Data were stratified by study design and pooled using random effects models.  A total of 20 studies were found to meet inclusion criteria; 18 studies were observational and 2 were RCTs.  In observational studies, DES were associated with a reduction in MACE (odds ratio [OR] 0.50, 95 % CI: 0.35 to 0.72), death (OR 0.69, 95 % CI: 0.53 to 0.91), TVR (OR 0.54, 95 % CI: 0.37 to 0.79), and TLR (OR 0.54, 95 % CI: 0.37 to 0.78).  The incidence of MI was similar between groups.  In the RCTs, pooled results were inconclusive because of small sample sizes.  The authors concluded that although data from observational studies suggest that the use of DES for vein graft stenosis has favorable effects on MACE, death, TVR, and TLR, these data should be interpreted with caution due to their observational nature.  Corresponding RCT data are inconclusive.  There remains a need for large multi-center RCTs to address the safety and effectiveness of DES for vein graft stenosis.

McLoughlin and Byrne (2008) stated that self expanding metal stents (SEMS) play an important role in the management of patients with malignant obstructing lesions in the gastrointestinal tract.  Traditionally, they have been used for palliation in malignant gastric outlet and colonic obstruction as well as esophageal malignancy.  The development of the polyflex stent, which is a removable self expanding plastic stent, allows temporary stent insertion for benign esophageal disease and possibly for patients undergoing neoadjuvant chemotherapy prior to esophagectomy.  Potential complications of SEMS insertion include perforation, tumor overgrowth or ingrowth, and stent migration.  Newer stents are being developed with the aim of increasing technical and clinical success rates, while reducing complication rates.  Other areas of development include biodegradable stents for benign disease and radioactive or drug-eluting stents for malignant disease.  It is hoped that, in the future, newer stents will improve our management of these difficult conditions and, possibly, provide prognostic as well as symptomatic benefit in the setting of malignant obstruction.

Katsanos et al (2010) noted that minimally invasive image-guided insertion of SEMS in the upper gastrointestinal tract is the current treatment of choice for palliation of malignant esophageal or gastro-duodenal outlet obstructions.  These investigators presented a concise review of contemporary stenting practice of the upper gastrointestinal tract, and the procedures in terms of appropriate patient evaluation, indications, and contra-indications for treatment were analyzed, along with available stent designs, procedural steps, clinical outcomes, inadvertent complications, and future technology.  Latest developments include biodegradable polymeric stents for benign disease and radioactive or drug-eluting stents for malignant obstructions.

Nakagawa (2011) stated that the effectiveness of the use of DES in the treatment of STEMI, a representative condition of acute coronary syndrome, is still unknown.  In this article, data of registry, randomized, and meta-analyses studies were reviewed.  Drug eluting stents showed a consistent trend toward decreasing the risk of repeat re-vascularization without increasing the incidence of death, recurrent MI, and stent thrombosis as compared to BMS.  The findings concerning the use of DES in patients with STEMI are: (i) its short-term effect of reducing the re-stenosis and repeat re-vascularization rates is evident; (ii) no randomized studies have demonstrated the usefulness of DES in the prevention of death and recurrent MI; (iii) no randomized or meta-analyses studies have shown results sufficient to eliminate long-term safety concerns; and most importantly, and (iv) there are no data clearly indicating safety concerns.

Palmerini et al (2012) compared the risk of thrombosis between BMS and DES.  For this network meta-analysis, RCTs comparing different DES, or DES with BMS currently approved in the United States were identified through Medline, Embase, Cochrane databases, and proceedings of international meetings.  Information about study design, inclusion and exclusion criteria, sample characteristics, and clinical outcomes was extracted.  A total of 49 trials including 50,844 patients randomly assigned to treatment groups were analysed.  One-year definite stent thrombosis was significantly lower with cobalt-chromium everolimus eluting stents (CoCr-EES) than with BMS (odds ratio [OR] 0.23, 95 % CI: 0.13 to 0.41).  The significant difference in stent thrombosis between CoCr-EES and BMS was evident as early as 30 days (OR 0.21, 95 % CI: 0.11 to 0.42) and was also significant between 31 days and 1 year (OR 0.27, 95 % CI: 0.08 to 0.74).  CoCr-EES were also associated with significantly lower rates of 1-year definite stent thrombosis compared with paclitaxel-eluting stents (OR 0.28, 95 % CI: 0.16 to 0.48), permanent polymer-based sirolimus-eluting stents (OR 0.41, 95 % CI: 0.24 to 0.70), phosphorylcholine-based zotarolimus-eluting stents (OR 0.21, 95 % CI: 0.10 to 0.44), and Resolute zotarolimus-eluting stents (OR 0.14, 95 % CI: 0.03 to 0.47).  At 2-year follow-up, CoCr-EES were still associated with significantly lower rates of definite stent thrombosis than were BMS (OR 0.35, 95 % CI: 0.17 to 0.69) and paclitaxel-eluting stents (OR 0.34, 95 % CI: 0.19 to 0.62).  No other DES had lower definite thrombosis rates compared with BMS at 2-year follow-up.  The authors concluded that in RCTs completed to date, CoCr-EES has the lowest rate of stent thrombosis within 2 years of implantation.  The finding that CoCr-EES also reduced stent thrombosis compared with BMS, if confirmed in future RCTs, represents a paradigm shift.

De Luca and colleagues (2012) performed a meta-analysis using individual patient data to evaluate the long-term safety and effectiveness of DES compared with BMS in patients undergoing primary PCI for STEMI.  Formal searches of electronic databases (MEDLINE and CENTRAL) and scientific session presentations from January 2000 to June 2011 were carried out.  These investigators examined all completed randomized trials of DES for STEMI.  Individual patient data were obtained from 11 of 13 trials identified, including a total of 6,298 patients (3,980 [63.2 %] randomized to DES [99 % sirolimus-eluting or paclitaxel-eluting stents] and 2,318 [36.8 %] randomized to BMS).  At long-term follow-up (mean [SD], 1,201 [440] days), DES implantation significantly reduced the occurrence of TVR (12.7 % versus 20.1 %; hazard ratio [95 % CI], 0.57 [0.50 to 0.66]; p < 0.001, p value for heterogeneity, 0.20), without any significant difference in terms of mortality, re-infarction, and stent thrombosis.  However, DES implantation was associated with an increased risk of very late stent thrombosis and re-infarction.  The authors concluded that the present pooled patient-level meta-analysis demonstrated that among patients with STEMI undergoing primary PCI, sirolimus-eluting and paclitaxel-eluting stents compared with BMS are associated with a significant reduction in TVR at long-term follow-up.  Although there were no differences in cumulative mortality, re-infarction, or stent thrombosis, the incidence of very late re-infarction and stent thrombosis was increased with these DES.

Werner et al (2012) presented the 5-year angiographical and clinical results of a retrospective registry assessing the performance of sirolimus-eluting stents (SES) in the treatment of infra-popliteal atherosclerotic disease.  From 2004 to 2009, a total of 158 patients (95 men; mean age of 71.9 years) with chronic lower limb ischemia (Rutherford categories 3 to 6) underwent primary SES placement in focal infra-popliteal lesions.  The angiographical endpoint was patency, defined as freedom from in-stent stenosis (ISS) greater than 50 %.  Clinical endpoints were death, amputation, and bypass surgery.  Results were correlated with patient and lesion characteristics and cumulative outcomes were assessed with Kaplan-Meier analysis.  Technical success was achieved in all cases.  The primary patency rates were 97.0 % after 6 months, 87.0 % after 12 months, and 83.8 % at 60 months.  In-stent stenosis was predominantly observed in the first year after stent placement.  Female gender was associated with a higher rate of ISS.  During clinical follow-up of 144 (91 %) patients over a mean 31.1 +/- 20.3 months, there were 27 (18.8 %) deaths, 4 (2.8 %) amputations, and no bypass surgery.  Clinical status improved in 92 % of the patients with critical limb ischemia (CLI) and 77 % of the patients suffering from claudication (p = 0.022).  The authors concluded that treatment of focal infra-popliteal lesions with SES showed encouraging long-term angiographical results in this registry.  Clinical improvement was evident, but more pronounced in CLI patients than in patients suffering from claudication.  They stated that further studies are needed to evaluate the potential clinical benefit of SES as compared to balloon angioplasty or BMS in the treatment of infra-popliteal lesions.

Athappan and Ponniah (2009) stated that studies on percutaneous transluminal cardiac angioplasty (PTCA) in patients with end stage renal disease (ESRD) on hemodialysis (HD) have suggested high rates of procedural complications and re-stenosis.  Bare metal stent PCI has significantly reduced re-stenosis and subsequent TLR in these patients, although not to the level of non-hemodialysis (NH) controls.  The introduction of DES has dramatically reduced re-stenosis rates compared with BMS in patients with various clinical and angiographic characteristics, however their impact on patients with ESRD on dialysis is unclear due to consistent exclusion of this population from major trials.  The purpose of this study was therefore to compare the outcomes of PCI with DES and BMS when used for ESRD patients on HD, by meta-analytical techniques.  Comparative studies published between January 2002 and January 2009 of DES versus BMS in ESRD patients on dialysis were identified using an electronic search and reviewed using a random effects model.  The primary endpoints of this study were the hard endpoints of mortality, MI and TLR.  A secondary endpoint of this analysis was late luminal loss.  In-hospital mortality and MI were also assessed.  Heterogeneity was assessed using Cochrane Q and I(2) statistics.  A total of 5 reports comprising 641 patients (279 DES, and 362 BMS) were included in the analysis.  All the studies were non-randomized comparisons between DES and BMS.  The length of follow-up was in the range between 9 and 12 months.  In-hospital clinical outcomes were similar between the 2 groups.  At follow-up there was a trend towards lower TLR (OR 0.50, CI: 0.27 to 0.93, p = 0.011 I(2) = 48 %) and decreased late luminal loss (WMD -0.34, CI: -0.58  to 0.10, p = 0.09, I(2) = 58 %) in patients undergoing PCI with implantation of DES.  There was no difference in the rates of all-cause mortality (OR 0.66, CI: 0.40 to 1.08, p = 0.070, I(2) = 0 %), and MI (OR 1.35, CI: 0.52 to 3.52, p = 0.53, I(2) = 0 %) between the 2 groups.  The authors concluded that in ESRD patients on HD undergoing PCI, DES are safe and reduce repeat revascularizations.  Moreover, they noted that the limited number of patients as well as the limited quality of primary studies included need careful interpretation of these results.  They stated that further well-designed, large RCTs are needed to establish the strategy of management in ESRD patients undergoing PCI.

The potential superiority of DES over BMS in reducing TLR or TVR in patients with ESRD on HD has not been established.  Small studies comparing DES to BMS in this population have yielded inconclusive results mainly due to the small sample size.  Abdel-Latif et al (2010) examined the total weight of evidence regarding the use of DES and BMS in patients with ESRD.  These investigators searched MEDLINE, EMBASE, Science Citation Index, CINAHL, and the Cochrane CENTRAL database of controlled clinical trials (December 2009) for controlled trials comparing DES to BMS in ESRD patients.  They conducted a fixed-effects meta-analysis across 7 eligible studies (n = 869 patients).  Compared with BMS-treated patients, DES-treated patients had significantly lower TLR/TVR (OR 0.55 CI: 0.39 to 0.79) and major adverse cardiac events (MACE) (OR 0.54; CI: 0.40 to 0.73).  The absolute risk reduction (ARR) with DES in TLR/TVR was -0.09 (CI: -0.14 to -0.04; NNT 11) and in MACE was -0.13 (CI: -0.19 to -0.07; NNT 8).  A trend towards lower incidence of all-cause mortality was also noted with DES (OR 0.68; CI: 0.45 to 1.01).  No significant differences were noted between the 2 groups in the relative or absolute risk of MI.  The authors concluded that the use of DES in patients with ESRD is safe and yields significant reduction in the risk of TLR/TVR and MACE.  Moreover, they stated that larger RCTs are needed to confirm the results of this meta-analysis and establish the appropriate stent choice in this high-risk population.

Otsuka et al (2011) stated that long-term outcomes after SES implantation in HD patients have remained controversial.  These researchers investigated the impact of HD on outcomes after SES implantation.  They analyzed the data on 2,050 patients who underwent SES implantation in a multi-center prospective registry in Japan.  Three-year clinical outcomes were compared between the HD group (n = 106) and the NH group (n = 1,944).  At the 3-year clinical follow-up, the rates of unadjusted cardiac mortality (HD: 16.3 versus NH: 2.3 %) and TLR (HD: 19.4 versus NH: 6.6 %) were significantly higher in the HD group than the NH group (p < 0.001).  Although HD group had a numerically higher stent thrombosis rate, the difference in stent thrombosis between the 2 groups (HD: 2.0 versus NH: 0.7 %) did not reach statistical significance.  Using Cox's proportional-hazard models with propensity score adjustment for baseline differences, the HD group had higher risks of TLR [HD: 16.3 versus NH: 6.1 %; HR, 2.83; 95 % CI: 1.62 to 4.93, p = 0.0003] and cardiac death (HD: 12.3 versus NH: 2.3 %; HR, 5.51; 95 % CI: 2.58 to 11.78, p < 0.0001).  The consistent results of analyses, whether unadjusted or adjusted for other baseline clinical and procedural differences, identify HD as an independent risk factor for cardiac death and TLR.  The authors concluded that PCI with SES in HD patients has a higher incidence of repeat revascularization and mortality compared with those in NH patients.  Moreover, HD appears to be strongly associated with mortality and repeat revascularization even after SES implantation.

Charytan et al (2011) examined the long-term clinical outcomes following DES or BMS placement in patients with severely reduced glomerular filtration rate (GFR).  All adults with chronic kidney disease (CKD) and severely decreased GFR (GFR; serum creatinine greater than 2.0 mg/dL or dialysis dependence) undergoing PCI with stent placement between April 1, 2003, and September 30, 2005, at all acute-care nonfederal hospitals in Massachusetts were included in this analysis.  Patients were classified as DES-treated if all stents were drug eluting and BMS-treated if all stents were bare metal.  Patients treated with both types of stents were excluded from the primary analysis.  2-year crude mortality risk differences (drug-eluting - bare-metal stents) were determined from vital statistics records, and risk-adjusted mortality, MI, and revascularization differences were estimated using propensity score matching of patients with severely reduced GFR based on clinical and procedural information collected at the index admission.  A total of 1,749 patients with severely reduced GFR (24 % dialysis dependent) were treated with DES (n = 1,256) or BMS (n = 493) during the study.  Overall 2-year mortality was 32.8 % (unadjusted DES versus BMS; 30.1 % versus 39.8 %; p < 0.001).  After propensity score matching 431 patients with a DES to 431 patients with a BMS, 2-year risk-adjusted mortality, MI, and TVR rates were 39.4 % versus 37.4 % (risk difference, 2.1 %; 95 % CI: -4.3 to 8.5; p = 0.5), 16.0 % versus 19.0 % (risk difference, -3.0 %; 95 % CI: -8.2 to 2.1; p = 0.3), and 13.0 % versus 17.6 % (risk difference, -4.6 %; 95 % CI: -9.5 to 0.3; p = 0.06).  The authors concluded that in patients with severely decreased GFR, treatment with DES was associated with a modest decrease in TVR not reaching statistical significance and was not associated with a difference in risk-adjusted rates of mortality or MI at 2 years compared with BMS.

Green et al (2011) examined the safety and effectiveness of DES in patients with CKD not on renal replacement therapy.  Patients were drawn from the National Heart, Lung, and Blood Institute Dynamic Registry and were stratified by renal function based on estimated GFR.  Of the 4,157 participants, 1,108 had CKD ("low GFR" less than 60 ml/min/1.73 m(2)), whereas 3,049 patients had normal renal function ("normal GFR" greater than or equal to 60 ml/min/1.73 m(2)).  For each stratum of renal function, these investigators compared risk of death, MI, or repeat revascularization between subjects who received DES and BMS at the index procedure.  Patients with low GFR had higher 1-year rates of death and MI and a decreased rate of repeat revascularization compared to patients with normal GFR.  Use of DES was associated with a decreased need for repeat revascularization in the normal-GFR group (adjusted HR 0.63, 95 % CI: 0.50 to 0.79, p <0.001) but not in the low-GFR group (HR 0.69, 95 % CI: 0.45 to 1.06, p = 0.09).  Risks of death and MI were not different between the 2 stents in either patient population.  The authors concluded that the presence of CKD predicted poor outcomes after PCI with high rates of mortality regardless of stent type.  Moreover, the effect of DES in decreasing repeat revascularization appeared to be attenuated in these patients.

Also, an UpToDate review on “Use of stents for venous stenosis associated with dialysis vascular access” (Beathard, 2013) states that “Although not yet evaluated clinically for dialysis vascular access, there is preliminary evidence in animals that sirolimus-eluting stents may provide short-term effectiveness in animal model arteriovenous grafts”.

Ma and colleagues (2012) stated that “Although some non-biodegradable polymer-coated DES claimed to be safe long-term, there remains caution regarding the inflammatory response.  Thus, biodegradable polymers are being considered and investigated to store and deliver drugs.  The most commonly used polymers now are poly(lactic acid) (PLA), poly(glycolic acid) and their copolymer, poly(lactic-co-glycolic acid) (PLGA), which can be fully degraded and metabolized by the body.  A multitude of biodegradable polymer-coated stents are currently in clinical trials.  For example, the Sparrow™ NiTi stent system (Surmodics Inc., Eden Prairie, MN, USA) employs SynBiosys™ biodegradable polymer PLGA to elute sirolimus; the CE-approved Biomatrix® stent (Biosensors International, Singapore), which was licensed to Terumo Corporation (Tokyo, Japan) with a new brand name (Nobori®) in May 2007, releases a sirolimus analogue, biolimus A9, from PLA coated on 316L stainless steel stent platform; both Excel® (JW Medical Systems, China) and Cura™ (OrbusNeich Medical, Inc., FL, USA) are PLA and sirolimus-coated stainless steel stents; Conor Medstent™ stent (Conor Medsystems, CA, USA) uses PLGA while Infinnium™ stent (Sahajanand Medical Technologies, India) utilizes PLA to elute paclitaxel.  In spite of many promising preliminary results, the development of biodegradable polymers in DES is still a challenge”.

Ye and colleagues (2013) noted that DES with biodegradable polymers (BP) have been developed to address the risk of thrombosis associated with 1st-generation DES.  These researchers determined the safety and effectiveness of BP biolimus-eluting stents (BP-BES) versus durable polymer (conventional) DES (DP-DES).  Systematic database searches of MEDLINE (1950 to June 2013), EMBASE (1966 to June 2013), the Cochrane Central Register of Controlled Trials (Issue 6 of 12, June 2013), and a review of related literature were conducted.  All RCTs comparing BP-BES versus DP-DES were included.  A total of 8 RCTs investigating 11,015 patients undergoing PCI were included in the meta-analysis.  The risk of major adverse cardiac events did not differ significantly between the patients treated with the BP-BES and the DP-DES (RR, 0.970; 95 % CI: 0.848 to 1.111; p = 0.662).  However, BP-BES was associated with reduced risk of very late ST compared with the DP-DES, while the risk of early or late ST was similar (RR for early or late ST, 1.167; 95 % CI: 0.755 to 1.802; p = 0.487; RR 0.273; 95 % CI: 0.115 to 0.652; p = 0.003; p for interaction = 0.003).  The authors concluded that in this meta-analysis of RCTs, treatments with BP-BES did not significantly reduce the risk of major adverse cardiac events, but demonstrated a significantly lower risk of very late ST when compared to DP-DES.  They stated that this conclusion requires confirmation by further studies with long-term follow-up.

Navarese et al (2014) stated that the safety and effectiveness of polymer-free DESs in clinical practice is currently subject of debate; RCTs conducted so far provided conflicting results or were under-powered to definitively address this question.   These investigators examined the safety and effectiveness profile of polymer-free versus DP-DES by a comprehensive meta-analysis of RCTs.  MEDLINE, Google Scholar, EMBASE and Cochrane databases were searched for RCTs comparing polymer-free to DP-DES.  Safety end-points at short-term (less than or equal to 1 year) and long-term follow-up (greater than 1 year) were: death, MI and stent thrombosis (ST); main effectiveness end-points were: TLR and TVR.  A total of 8 RCTs including 6,178 patients were included.  No significant differences in mortality were observed between polymer-free and DP-DESs at both short- and long-follow up (OR [95 % CI]: 0.79 [0.58 to 1.08], p = 0.14; and 0.80 [0.58 to 1.10], p = 0.17 respectively); polymer free and DP-DESs provided comparable short and long-term MI rates; at short-term: OR [95 % CI]: 1.13 [0.83 to 1.54], p = 0.44 and at long-term: OR [95 % CI]: 1.27 [0.87 to 1.85], p = 0.22.  Similarly, these 2 different devices proved equally effective in regards to ST, TLR and TVR over the short and long follow-up period.  The authors concluded that polymer-free DESs are as safe and effective as DP-DES; however, there is no evidence of any additional benefits provided by this new technology.

Palmerini and associates (2014) examined the relative safety and effectiveness of bioabsorbable polymer-based BES versus DP-DES and DP-BMS by means of a network meta-analysis.  Randomized controlled trials comparing bioabsorbable polymer-BES versus currently U.S.-approved DES or BMS were searched through MEDLINE, EMBASE, and Cochrane databases.  Information on study design, inclusion and exclusion criteria, sample characteristics, and clinical outcomes was extracted.  Data from 89 trials including 85,490 patients were analyzed.  At 1-year follow-up, bioabsorbable polymer-BES were associated with lower rates of cardiac death/ MI, MI, and TVR than BMS and lower rates of TVR than fast-release zotarolimus-eluting stents.  The bioabsorbable polymer-BES had similar rates of cardiac death/MI, MI, and TVR compared with other 2nd-generation DP-DES but higher rates of 1-year ST than cobalt-chromium everolimus-eluting stents (CoCr-EES).  The bioabsorbable polymer-BES were associated with improved late outcomes compared with BMS and paclitaxel-eluting stents, considering the latest follow-up data available, with non-significantly different outcomes compared with other DP-DES although higher rates of definite ST compared with CoCr-EES.  The authors concluded that in this large-scale network meta-analysis, bioabsorbable polymer-BES were associated with superior clinical outcomes compared with BMS and 1st-generation DES and similar rates of cardiac death/MI, MI, and TVR compared with 2nd-generation DP-DES but higher rates of definite ST than CoCr-EES.

Zhang (2014) noted that delayed re-endothelialization may be the pathophysiological cause of ST.  Biodegradable polymer DES (BP-DES) may reduce the risk of ST.  These investigators evaluated the risk of ST in patients treated with BP-DES.  Studies were retrieved from the PubMed, Cochrane Library, and EMBASE online databases.  A total of 12 studies (15,155 patients) with long-term follow-up (greater than or equal to 12 months) were included.  Compared with DP-DES, BP-DES did not significantly decrease the risk of definite and probable ST (RR, 0.89; 95 % CI: 0.68 to 1.18; p = 0.425) and definite ST (RR, 0.92; 95 % CI: 0.66 to 1.30; p = 0.648).  Furthermore, there was no difference in the risk of late ST (RR, 1.17; 95 % CI: 0.39 to 3.53; p = 0.780).  However, the rate of early ST was slightly higher in the BP-DES group (RR, 1.60; 95 % CI: 0.94 to 2.73; p = 0.084) than in the DP-DES group.  A significant reduction in very late ST (greater than 12 months) was evident with the BP-DES group (RR, 0.27; 95 % CI: 0.10 to 0.68; p = 0.006).  Subgroup analysis showed that there was no difference in the rate of definite and probable ST between the BP-DES and 1st- or 2nd-generation DES groups.  The authors concluded that biodegradable polymer stents were associated with a significantly lower risk of very late ST.  However, there was no difference in the risk of definite and probable ST between the 2 groups.

Wang and colleagues (2014) stated that BP-DES represent a promising strategy to improve the delayed healing and hypersensitive reaction in the vessel.  However, the safety and effectiveness of BP-DES versus permanent polymer DES (PP-DES) are less well-defined.  In a meta-analysis, these researchers compared the total, short (less than 30 days), mid (30 days to 1 year) and long (greater than 1 year) term outcomes of BP-DES versus PP-DES.  PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs to compare any of approved BP- and PP-DES.  Effectiveness end-points were TLR and in-stent late loss (ISLL).  Safety end-points were death, MI, and composite of definite and probable ST.  The meta-analysis included 19 RCTs (n = 18,395) with interesting results.  As compared with DES, there was a significantly reduced very late ST (OR [95 % CI]: 0.42 [0.24 to 0.77], p = 0.852) and ISLL (OR [95 % CI]: -0.07 [-0.12 to 0.02], p = 0.000) in BP-DES patients.  However, there were no differences between BP-DES and PP-DES for other safety and effectiveness outcomes, except that the stratified analysis showed a significant decreased TLR with BP-DES as compared to paclitaxel-eluting stent (OR [95 % CI]: 0.41 [0.20 to 0.81], p = 0.457).  The authors concluded that BP-DES are more effective in reducing very late ST and ISLL, as well as comparable to PP-DES with regard to death, TLR and MI.  Moreover, they stated that further large RCTs with long-term follow-up are needed to better define the relative merits of BP-DES.

Kwong and Yu (2014) systematically reviewed the latest randomized evidence on the safety and effectiveness of BP-DES as compared to DP-DES.  MEDLINE, Embase, and the Cochrane database were searched in August 2013 for eligible RCTs comparing BP-DES with DP-DES.  Clinical outcomes of interest were mortality, MI, TLR, TVR, and ST.  A total of 20 RCTs randomizing 20,021 participants were included, of whom 11,045 were allocated to BP-DES and 8,976 to DP-DES.  Treatment of BP-DES was not associated with a significant reduction of any of the clinical outcomes (all-cause mortality, OR: 0.94, 95 % CI: 0.80 to 1.10, p = 0.42; cardiovascular mortality, OR: 0.97, 95 % CI: 0.79 to 1.19, p = 0.74; MI, OR: 1.07, 95 % CI: 0.91 to 1.26, p = 0.41; TLR, OR: 0.87, 95 % CI: 0.69 to 1.08, p = 0.20; TVR, OR: 1.05, 95 % CI: 0.85 to 1.28, p = 0.67; definite/probable ST, OR: 0.80, 95 % CI: 0.59 to 1.07, p = 0.14).  The authors concluded that current randomized data indicate that clinical safety and effectiveness profiles of BP-DES are comparable to those of DP-DES.  Moreover, they stated that findings from large-scale studies with rigorous methodology and long follow-up duration are needed.

Niu and co-workers (2014) compared the short- and long-term outcomes and the ST risk in patients treated with BP-DES versus PP-DES.  These investigators searched Medline, Embase, Web of science, CENTRAL databases, and conference proceedings/abstracts for RCTs comparing BP-DES with PP-DES.  The primary end-point was to compare the risks of overall and different temporal categories definite/probable ST.  Other clinical outcomes were TLR, MI, and all-cause death in short-term (less than or equal to 1 year) and long-term follow-up.  The meta-analyses were performed by computing ORs with 95 % CIs using a random-effects model.  A total of 19 RCTs including 20,229 patients were analyzed.  Overall, BP-DES significantly decreased the risks of very late definite/probable ST (OR 0.33; 95 % CI: 0.16 to 0.70), and TLR in long-term follow-up (OR 0.70; 95 % CI: 0.52 to 0.95) compared with PP-DES.  There were no significant differences between the groups regarding MI incidence and mortality during both short- and long-term follow-up period.  In stratified analyses, the long-term superiority of BP-DES was only maintained by using 1st-generation DES as the comparators.  The authors concluded that the present meta-analysis indicated that BP-DES were more effective than PP-DES at reducing the risks of very late ST and long-term TLR, but it could vary by heterogeneities in the use of PP-DES comparators.  Moreover, they stated that additional rigorous RCTs with longer follow-up periods are needed to verify these very promising long-term end-points.

The Australian Safety and Efficacy Register of New Interventional Procedures – Surgical’s assessment on “Biodegradable stents” (ASERNIP-S, 2013) considers biodegradable polymer drug eluting stents to be investigational.  The authors stated that this assessment of biodegradable polymer stents for coronary artery disease (CAD) was based on a meta‐analysis of 10 RCTs, a large RCT and a single‐arm registry with 5 years of data.  The most rigorous evidence, a recent meta‐analysis, found no significant benefit of biodegradable stents for CAD with respect to death, MI or late ST, although benefits were found in rates of TLR and late lumen loss (LLL).  The authors postulated that the lack of demonstrated benefit could have been due to heterogeneity among studies for the TLR and LLL outcomes, and variation in types of non-biodegradable DES employed (with most being 1st versus 2nd generation DES).  As such, the findings of this meta‐analysis cannot be highly weighted.  Ideally, future studies should compare stents that utilize the same metal scaffold and anti‐proliferative drug, with the only difference being the presence of a durable versus biodegradable polymer, so that the true safety and effectiveness of biodegradable polymer DES can be determined.

A Wikipedia review on “Drug-eluting stent” (2014) indicated that “Clinical trials are currently examining two stents carrying everolimus, an analog of sirolimus.  Guidant, which has the exclusive license to use everolimus in drug-eluting stents, is the manufacturer of both stents.  The Guidant vascular business was subsequently sold to Abbott.  The Champion stent uses a bioabsorbable polylactic acid carrier on a stainless steel stent.  In contrast, its Xience stent uses a durable (non-bioabsorbable) polymer on a cobalt alloy stent.  One alternative to drug-eluting stents is a stent surface designed to reduce the neointimal proliferation.  One such is the Genous bioengineered stent.  In place of the stainless steel (and now cobalt chrome) currently used in stents, various biodegradable frameworks are under early phases of investigation.  Since metal, as a foreign substance, provokes inflammation, scarring, and thrombosis, biodegradable or bioabsorbable stents hopefully may prevent some of these effects.  A magnesium alloy-based stent has been tested in animals, though currently no carrier is available for drug elution.  A promising biodegradable framework is made from poly-L-lactide, a polymer of a derivative of L-lactic acid.  One of these stents, the Igaki-Tamai stent, has been studied in pigs; tranilast and paclitaxel have been used as eluted drugs”.  http://en.wikipedia.org/wiki/Drug-eluting_stent.

Furthermore, an UpToDate review on “Coronary artery stent types in development” (Cutlip and Abbott, 2014) states that “The coronary stents currently available are permanent implants composed of a metallic alloy.  Drug-eluting stents (DES) have additional durable polymer and anti-restenotic drug components.  While bare metal stents (BMS) and DES have improved outcomes for patients, they have several limitations.  The development of stent thrombosis after placement of BMS or DES and the residual rate of restenosis after DES are two reasons for the development of newer coronary artery stents.  This topic will present studies of coronary artery stent types that show promise for reduction in rates of these adverse outcomes, including DES with bioresorbable polymers vascular scaffolds.  The terms bioresorbable (also called biodegradeable) and bioabsorbable are used in this topic.  Bioresorbable refers to the complete breakdown and removal of a material over time and often by a known mechanism.  Bioabsorbable refers to incomplete breakdown; the material may be partially digested and remain indefinitely in local tissue.  Stent material and polymer may be bioresorbable or bioabsorbable …. A number of drug eluting stent models, including abciximab-coated, beta-estradiol, and dexamethasone stents, have been tested and not carried forward into regulatory approval clinical trials in the United States.  The Combo stent combines sirolimus elution from an abluminal biodegradable polymer matrix with a CD34 antibody layer.  The CD34 antibody is directed toward circulating endothelial progenitor cells with a goal of increasing the rate of cellular coverage and thus decreasing the rate of stent thrombosis.  In the first-in-man trial, the Combo stent was noninferior to a paclitaxel-eluting stent for outcomes of nine-month angiographic in-stent late lumen loss and 12-month major adverse cardiovascular events.  Newer stent types are being developed to overcome some of the limitations of current stents, such as the development of stent thrombosis after placement of any intracoronary stent and the residual rate of restenosis after drug-eluting stent (DES).  These newer stent types fall into three broad categories: stents with bioresorbable polymer; drug-eluting stents that are polymer free; or stents with a bioresorbable scaffold”.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
0075T - 0076T
37236 - 37237
37238 - 37239
61635
92928 - 92929
92933 - 92934
92937 - 92938
92941
92943 - 92944
HCPCS codes covered if selection criteria are met:
C1874 Stent, coated / covered, with delivery system system [covered for (FDA)-approved everolimus, paclitaxel, sirolimus, and zotarolimus eluting stents only] [not covered for biodegradable (bioresorbable, bioabsorbable) polymer drug eluting stents]
C1875 Stent, coated / covered, without delivery system system [covered for (FDA)-approved everolimus, paclitaxel, sirolimus, and zotarolimus eluting stents only] [not covered for biodegradable (bioresorbable, bioabsorbable) polymer drug eluting stents]
Other HCPCS codes related to the CPB:
C9600 - C9601 Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed
C9602 - C9603 Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed
C9604 - C9605 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed
C9606 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel
C9607 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel
C9608 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure
ICD-9 codes covered if selection criteria are met:
413.0 - 413.9 Angina pectoris
414.00 - 414.07, 414.2 - 414.9 Coronary atherosclerosis
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive) :
440.1 - 440.9 Atherosclerosis of renal artery and extremities
443.0 - 443.9 Other peripheral vascular disease
446.7 Takayasu's disease [aorto-arteritis]
447.1 Stricture of artery
537.0 Acquired hypertrophic pyloric stenosis (gastric outlet obstruction)
575.0 - 577.9 Other disorders of gallbladder, other disorders of biliary tract, and diseases of pancreas
750.5 Congenital hypertrophic pyloric stenosis
996.1 Mechanical complication of other vascular device, implant and graft [vein graft stenosis]
996.73 Other complications due to renal dialysis device, implant, and graft [venous stenosis associated with dialysis vascular access]


The above policy is based on the following references:
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