Stent Selection in Special-Risk Patients: A Decision Tree
Drug-eluting stents (DES) should be considered our routine choice in patients who tolerate dual-antiplatelet therapy (DAPT) for at least 3 months. In patients with a high bleeding risk, when DAPT is contraindicated, or in patients with a high risk of DAPT discontinuation within 30 days from stenting, bare-metal stents (BMS) should be the preferred type of stent. In patients with high risk of DAPT discontinuation between the first and the third month due to high bleeding risk, BMS should be preferred if the biolimus A9 (BA9)-coated stent is not available. If the BA9-coated stent is available, the choice should be made according to vessel size and lesion length, and mainly according to the risk of earlier or later DAPT discontinuation within the 3-month window. In patients who need surgery within 30 days from the stenting procedure, BMS should be preferred. When surgery is planned between the first and the third month after stenting, the choice between BMS and DES should be according to BA9-coated stent availability and the risk of restenosis as in patients at high bleeding risk. In patients with poor adherence to medical therapy, BMS should be preferred, especially when the coronary lesion appears to be at moderate-to-low risk for restenosis. In patients with atrial fibrillation on anticoagulant therapy, use of the BA9-coated stent and 1 month of DAPT should be considered. In patients at high bleeding risk, if the BA9-coated stent is not available, single antiplatelet therapy after DES is a reasonable alternative. BMS could be considered in coronary lesions at very low risk of restenosis (coronary vessel diameter ≥3.5 mm) in patients with a high bleeding risk profile. An additional pathway to be considered in the patient who has lesions at high risk for restenosis, and who really may benefit from a DES, is to perform transcatheter occlusion of the left atrial appendix and more safely continue DAPT. CABG = coronary artery bypass graft; LAA = left atrial appendage.