Evolving Paradigms in the Endovascular Treatment of Coronary Artery Disease [CAD]

Background: Endovascular treatment, or more simply and more practically speaking, the technical implementation of stents [or stent grafts, coils, plugs, etc.] into the blood vessel, still reasonably remains worldwide as definitely one of the most frequently used therapeutic options for Coronary Artery Disease [CAD]. This field of investigation is constantly evolving, extending from initial bare-metal vascular stents through drug-eluting stents and, more recently, introducing high-tech bioresorbable stents and polymer-free stents. However, despite so many advances, cardiovascular medicine has unfortunately failed so many times in various disease areas to effectively translate promising treatments from positive pre-clinical studies to successful clinical trial results. Despite that not-so-beautiful history part, the scientific community persists in testing new, putative therapeutic options using the same concepts, approaches, and methods without significant modifications. Methods: This article briefly reviews the historical evolution of these biomechanical apparatuses, from their inception, their advantages and shortcomings, workflow, and emphasizes how they could be further developed to provide an optimal vascular coronary stent and master some complex, undefined, and still unresolved practical situations and challenges in stent development. Additionally, it highlights the role of programmed algorithms like the SYNTAX score I and II, used for coronary artery disease grading and as very useful, practical decision-making tools. A special emphasis is also placed here on the so-called bifurcation lesion, due to its severity for treatment. Results: Coronary stents have generally revolutionized the field of interventional cardiology and undoubtedly significantly improved clinical outcomes in subjects with CAD. However, there are still several practically important flaws, including, for example, the everlasting risk of thrombosis [both acute and chronic] and its most severe consequences, due to traumatic procedural endothelial injury and, of course, in-stent restenosis, being still not a completely understood process. Conclusion: The newest generation gene-eluting stents, customized and semi-customized coronary stents with adjusted self-reporting stent sensors, are possible effective options to the established endovascular practice. Bearing in mind the moment adequacy and patency, and perhaps more importantly, their full promising potential, of the previously mentioned gene-eluting stents, customized coronary vascular stents produced by the newest 4D printing technologies and integrated self-reporting stent sensors could most probably have key roles in the mission of optimal coronary stent apparatuses development. Nevertheless, much more interventional practical results from large-scale studies are required to more precisely define the full prospects of these appealing stent innovations.