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Comment & Response
October 16, 2019

Ultrathin Strut Stents in Small Coronary Vessels—Are We There Yet?—Reply

Author Affiliations
  • 1Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, the Netherlands
  • 2Technical Medical Centre, Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, the Netherlands
JAMA Cardiol. Published online October 16, 2019. doi:https://doi.org/10.1001/jamacardio.2019.3915

In Reply We thank Al Hinai et al for their interest in our work.1 They raise the question whether one can separate the effect of strut size vs eluted drug or type of polymer. Based on our data, such a separation cannot be done, but as outlined in our article,1 we feel that strut thickness may be the most relevant characteristic of our study’s drug-eluting stents (DESs) with regard to the risk of target lesion revascularization. All 3 types of DESs use sirolimus or one of its derivatives, which have shown similar efficacy in suppressing in-stent neointimal proliferation in several studies. The duration of drug elution differed among the 3 DESs, and thus, an effect of dissimilar pharmacodynamics cannot be excluded. In addition, theoretically, a prolonged inflammation caused by durable polymer could accelerate the formation of neoatherosclerosis, which may be most relevant in small-vessel lesions. We cannot exclude that polymer type (ie, biodegradable vs durable) and distribution and degradation speed of biodegradable polymers could play a certain role. Nevertheless, if a minimum amount of polymer coating and a rapid polymer degradation would be most important for lowering the risk of repeated revascularization, the biodegradable polymer everolimus-eluting stent should have shown the lowest repeated revascularization rate. In addition, a 2017 meta-analysis with medium-term follow-up did not show superiority of biodegradable over durable polymer DES.2

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