Plain Old Balloon Angioplasty vs. Stents

Source: Versaci F, et al. N Engl J Med 1997;336:817-822.

Isolated proximal left anterior descending (LAD) coronary artery stenoses have always been ideal lesions for angioplasty because of superior results initially and long term as compared to other sites and other arteries. Recent studies applying coronary stents to a variety of lesions have demonstrated superior restenosis rates vs. plain old balloon angioplasty (POBA). Thus, Versaci et al studied 120 patients with isolated proximal LAD stenosis, angina and/or documented ischemia, and an ejection fraction of at least 40%. All patients were technically suitable for both techniques, which were randomly assigned. Initial success was similar in the two groups (95% stent vs 93% POBA). The 12-month event-free survival rates (no myocardial infarction, angina, or revascularization surgery) were 87% in the stent group and 70% after POBA (P < 0.04). Restenosis rates were 19% after stents and 40% after POBA (P < 0.02). The authors conclude that in symptomatic patients with isolated proximal LAD stenosis, stents were associated with lower restenosis rates and better clinical outcomes. This study is unlikely to change clinical practice since stentomania rules with the balloonatics. Current data suggest that coronary bypass surgery with the mammary artery provides superior freedom from long-term cardiac events as compared to POBA or medical therapy. Thus, the real issue is how stenting the proximal LAD would compare to the best surgical approach (minimal incision internal mammary graft?). Some caveats regarding stents are important: major peripheral vascular complications are higher vs. POBA (7% vs 0%) and hospital stay is longer (6.5 vs 5.0 days; P < 0.04). However, some of these problems were related to the aggressive anticoagulation protocol in this study that is no longer used. Finally, only patients with stenotic arteries at least 3 mm in diameter and less than 15 mm in length are currently candidates for stents. Thus, in select patients, stents truly are superior to POBA.—mhc