JACC: CARDIOVASCULAR INTERVENTIONS

VOL. 7, NO. 10, 2014

ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.

ISSN 1936-8798/$36.00 http://dx.doi.org/10.1016/j.jcin.2014.08.001

EDITOR’S PAGE

“They’ve Gone About as Far as They Can Go” Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions

W

e are still receiving many good clinical

avoiding this disaster (1). Yes, the stents are better

research papers on stenting, stenting

and the antiplatelet strategies may be better, but a

technology, and stenting outcomes, but

good measure of the improvement in outcomes re-

you may notice that papers on structural heart dis-

lates to the attention that has been paid to proper

ease and peripheral vascular disease sometimes

stent deployment with the goal of complete deploy-

outnumber those on coronary interventions. The

ment and apposition with smooth laminar flow

advances

seem

through the treated segment. This remains one of the

mature. Maybe we have gone so far that coronary

most effective antithrombotic measures we have.

stenting is no longer a big deal. A cardiology friend

Nonetheless, stent thrombosis, and especially late

of mine just returned from a cruise up the coast of

stent thrombosis, remains, and we must not become

Norway. One day at sea, the ship doctor asked him

too dependent on the stent or on the antiplatelet

to see a passenger who had chest pain. After an elec-

drugs to bail out suboptimal deployment techniques.

trocardiogram and enzymes showed abnormalities,

Two other papers with accompanying editorials

the passenger was lifted from the ship by helicopter

explore the correlates and outcomes of stent throm-

and delivered to a hospital in Trondheim where a

bosis (2–5). With the low prevalence of stent throm-

stent was placed in his 90% left anterior descending

bosis, it has been difficult to provide strong evidence

coronary artery lesion. Three days later, the passen-

for the magnitude and duration of antiplatelet ther-

ger was again enjoying a cocktail on the main deck

apy. Much of the evidence is provided in the state-

while admiring the scenic Nordic coastline. Is this

of-the-art paper, and ongoing clinical investigation

no big deal? Are we becoming blasé about the

continues to weigh the balance between adequate

marvelous results that can be achieved with the latest

antiplatelet therapy and bleeding risk.

in

coronary

interventions

may

stent technology? What could go wrong? Restenosis,

It is not in the nature of interventional cardiology

the “soft underbelly” of angioplasty as Richard Myler

or of those who develop the products we use to agree

called it, continues to recede from our consciousness,

that “they’ve gone about as far as they can go” (6).

and that is a good thing. When it does come back it is

New directions in stenting, including bioabsorbable

usually a benign visitor, and the main question is

stents, bifurcation stents, self-expanding stents, and

which effective therapy should be used to correct it.

the like, are mostly designed to reduce restenosis, but

The other culprit that is much more sinister is, and

their relationship to stent thrombosis needs careful

always has been, stent thrombosis. New stent tech-

examination not only in clinical trials, but also in the

nology, deployment techniques, and antithrombotic

more complex situations in which they may be used

therapy have made it rare, but when it comes to

after general release. Keeping track of stent throm-

call, it is devastating. Some studies show that stent

bosis is not an easy assignment, because many events

thrombosis is far below 1%, so it is easy to discount

occur out of the hospital; weeks, months, or years

it as a problem. This discounting, however, may itself

after implantation; and often at locations remote

be a problem.

from the hospital where the stent was originally

In this issue of JACC: Cardiovascular Interventions,

placed. Post-market surveillance methods are critical

an excellent state-of-the-art paper reviews the prob-

for stent designs that are markedly different from

lem of stent thrombosis from its early days to the

those with which we have extensive experience. We

current state and emphasizes the various means of

may not have gone as far as we can go, but we have

King

JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 10, 2014 OCTOBER 2014:1202–3

Editor’s Page

gone a long way toward mitigating stent thrombosis.

for publication in this journal. Along with the surge

Future stent designs and materials should be held to

in structural heart and peripheral vascular sub-

the high standard that has been established. As

missions, the continued interest in coronary stent-

operators become more confident in addressing more

ing has been a significant factor in the recently

complex lesions, they also must pay exquisite atten-

released impact factor of 7.44 (the highest for any

tion to technique, not only to achieve an initial result,

subspecialty journal in cardiology). We, the editors,

but also to protect the patient for years to come.

are pleased, but we also hope we have not gone as

As JACC: Cardiovascular Interventions continues

far as we can go.

to mature, we will try to reflect the issues of greatest interest to practicing interventional cardi-

ADDRESS

ologists, scientists, engineers, and researchers as the

King III, MD, MACC, Saint Joseph’s Heart and

CORRESPONDENCE

TO:

field itself matures and evolves. We are proud that

Vascular Institute, 5665 Peachtree Dunwoody Road

those of you continuing to investigate improve-

NE, Atlanta, Georgia 30342. E-mail: spencer.king@

ments in stenting are submitting excellent studies

emoryhealthcare.org.

Spencer

B.

REFERENCES 1. Claessen BE, Henriques JPS, Jaffer FA, Mehran R, Piek JJ, Dangas GD. Stent thrombosis: a clinical perspective. J Am Coll Cardiol Intv 2014;7:1081–92. 2. Waksman R, Kirtane AJ, Torguson R, et al., on behalf of the DESERT Investigators. Correlates and outcomes of late and very late drug-eluting stent thrombosis: results from DESERT (International

Drug-Eluting Stent Event Registry of Thrombosis). J Am Coll Cardiol Intv 2014;7:1093–102.

results from a multicenter registry. J Am Coll Cardiol Intv 2014;7:1105–13.

3. Mauri L, Galper BZ. Late stent thrombosis: can it be prevented? J Am Coll Cardiol Intv 2014;7: 1103–4.

5. Valgimigli M. Shifting the focus to recurrences:

4. Armstrong EJ, Sab S, Singh GD, et al. Predictors and outcomes of recurrent stent thrombosis:

6. Rodgers R, Hammerstein O. Oklahoma! [musical]. New York, 1943.

so good we can afford it or too bad we cannot avoid it? J Am Coll Cardiol Intv 2014;7:1114–6.

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