Two stents Onyx (Medtronic) and Biofreedom(Biosensors) appear promising with rapid endothelisation and hence short DAPT. There are three more options, available for this situation.
Option 1
Avoid the endothelium unfriendly DES and use BMS* with MAPT (Mono or minimal duration antiplatelet therapy). For the sake of young generation cardiologists, let me expand BMS,ie Bare metal stents.
BMS in 2020 , what nonsense are you talking about ? (For those who ask this question, please go through the following study with a conscience)
(NORSTENT 2016 -One of the most underrated, deliberately concealed landmark paper in cardiology. We understand, even papers from NEJM don’t get noticed, if it confronts commerce. As expected, none of the cardiology bodies considered it worthy to use this study data in CAD management guidelines)
Want more evidence?
One more study, BASKET -PROVE explicitly showed in large-caliber vessel (Stent >3mm) BMS vs DES doesn’t make any difference.(Christoph Kaiser 2010 NEJM)
What is the 2nd and 3rd option?
Did you guess it ? Yes, correct, avoid the stent altogether. Do a POBA* if feasible, or just continue with the self humiliating medical management and be happy to prevent a potential stroke.
Mind you, in our hind sight, we always realise, most lesions are amenable for medical management, unless it is critical, proximal and symptomatic.
*If you think doing POBA downgrades your Interventional worthiness, we may add a DEB top up, to pacify our restless scientistic sense.
- DEB -Drug-eluting balloon (A huge emerging market coming up as an alternative to DES FabienPicard et all Archives of cardiovascular disease 2017)
BVS(Bioreabsorbable vascular scaffold)
It is not yet ready as on option, since it appears risky even with 60 micron struts as stent digestion is patchy and incomplete and paradoxically create a more thrombotic milieu.
Final message
In high bleed risk patients, though special stents are avialable, BMS is always an option.
Postamble
After seeing this , one of my colleagues told me, two weeks of vigorous search all through India, he failed to get a single BMS supplier. When enquired, I also found the same. Yes, India is a poor country, they can’t afford to stock cheap BMS, try asking rich western countries. I am sure Germany has it.
( Scientifically, the option of BMS need not be confined to high bleeding risk ,it can very well extend to any CAD profile)
What Dr Antanio Colombo has to say on this
https://www.sciencedirect.com/science/article/pii/S0735109717376064
Dr.S.Venkatesan MD 