Very Late Outcomes of Drug-Eluting Stents: The "Catch-Down" Phenomenon

Based on the current paradigm, drug-eluting stents (DES) are not only more effective, but also safer than bare metal stents (BMS).1 Certainly, it was not always so: in spite of their lower risk of restenosis and target lesion revascularization (TLR) compared with BMS, first-generation DES have been blamed for years due to concerns of a ‘catch-up’ in late and very late ischaemic events that pathological and in vivo studies attribute to delayed arterial healing, polymer hypersensitivity reactions, continuous neointimal growth, late-acquired malapposition, and neoatherosclerosis.2,3 Second-generation DES with biocompatible polymers, biodegradable polymers, or polymer-free—along with improved platform design, thinner struts, and novel antiproliferative drugs—have now addressed many of these limitations, translating into better clinical outcomes. In a network meta-analysis of> 52 000 patients summarizing data from a total of 51 stent trials at a median follow-up of 4 years, second-generation DES were found to outperform BMS and firstgeneration DES significantly with respect to both safety and efficacy