Coronary stenting remains one of the most common interventions in cardiology practice. While the procedure itself has become routine, choosing the right stent is anything but simple. The decision impacts not only immediate angiographic success but also long-term outcomes, including restenosis rates, antiplatelet therapy tolerance, and overall quality of life.
As stents continue to evolve, so must the clinical reasoning behind their selection. This article outlines the key considerations when choosing a stent, providing a practical lens for treating physicians.
Why Stent Selection Matters
A stent is not a temporary fix. Once deployed, it becomes an integral part of the vessel wall, influencing endothelial healing, inflammation, and the need for antiplatelet therapy. Making the right choice supports:
- Lower restenosis and reintervention rates
- Reduced bleeding risk with optimised therapy durations
- Better patient compliance
- Safer outcomes in complex or comorbid cases
The long-term impact of this decision is why stent selection deserves thoughtful clinical consideration.
Understanding the types of cardiac stents
Over the past two decades, the landscape of stents has shifted significantly. While the available categories may appear straightforward, understanding the subtle but critical differences is essential in guiding therapy.
Bare-metal stents were the first to be introduced. They provide mechanical scaffolding without any drug release. Today, their use is largely restricted to patients who cannot tolerate even short durations of antiplatelet therapy.
The majority of current procedures involve drug-eluting stents vs bare-metal stents. Now the standard of care, drug eluting stent releases antiproliferative drugs that significantly lower the risk of restenosis and reintervention They are preferred in patients with diabetes, diffuse disease, or high thrombotic risk. Among drug-eluting options, it is important to differentiate between first- and second- generation platforms. First-generation stents had thicker struts and durable polymers, which raised the risk of late thrombosis.
Modern second-generation stents have thinner struts, more biocompatible or biodegradable polymers, and improved delivery systems. Polymer-free stents represent a growing sub-category. These stents eliminate the polymer component entirely to reduce chronic inflammation. They are particularly useful in patients where antiplatelet therapy needs to be curtailed, such as those undergoing planned surgery or with a history of bleeding complications. Bioresorbable scaffolds are another class, although still limited in use. While the idea of a disappearing scaffold is attractive, clinical data have not consistently shown superiority. These are currently considered in selected patients with simple lesions and good adherence profiles.
Clinical Decision Factors in how to choose a stent The process of selecting a stent is shaped by three core considerations. Organising these factors into anatomical, clinical, and therapeutic domains can support a more structured discussion during case planning.
1. Anatomical Complexity
Lesion characteristics such as location, vessel diameter, calcification, bifurcations, and length all influence the choice. In complex lesions, a stent with better deliverability and conformability may be preferred. Intravascular imaging techniques such as IVUS and OCT should be used whenever possible to optimise decision making.
2. Clinical Comorbidities
Patients with diabetes typically benefit more from drug-eluting stents, especially newergeneration ones with ultrathin struts. In patients with chronic kidney disease or bleeding tendencies, balancing restenosis risk with DAPT duration becomes critical. Here, polymer-free stents or those that allow for shorter therapy can be considered.
3. Pharmacological Considerations
The patient’s ability to tolerate prolonged antiplatelet therapy is often the deciding factor. If long-term DAPT is not feasible, the choice of stent must reflect that. This issue is sometimes repeated across multiple consultation stages, so consolidating the discussion during planning helps maintain clarity.
Reducing medication duration may be necessary in elderly patients, those with prior GI bleeds, or patients scheduled for non-cardiac surgery. A unified discussion with the surgical and primary care team ensures consistency in risk management.
Procedural Insights into how to choose stent size
Proper stent sizing is not guesswork. It is based on real-time imaging, reference vessel diameter, and lesion length.
In practice, this involves:
- Using IVUS or OCT to measure proximal and distal reference diameters
- Matching stent diameter closely to vessel size
- Ensuring full lesion coverage, including small edges
- Performing post-dilation to optimise apposition and expansion
Incorrect sizing can lead to complications such as stent migration, malapposition, or vessel injury. Focusing on these procedural details helps improve both angiographic and clinical outcomes.
Practical stent selection guide for Cardiologists
Rather than a one-size-fits-all checklist, the following framework can be used as part of a collaborative planning tool involving the interventionalist, cardiologist, and if needed, the referring physician or surgeon.
- Does the lesion have anatomical complexity that warrants imaging guidance?
- Can the patient adhere to DAPT, and for how long?
- Are there existing comorbidities affecting vascular healing or medication tolerance?
- Is the patient undergoing surgery within the next year?
- Is there financial or systemic access to follow-up care or newer platforms?
This approach helps ensure the stent choice is part of a broader clinical decision, not an isolated procedure step. Third-generation cobalt chromium sirolimus- and everolimus-
eluting stents offer significant advantages in this context. These platforms are designed with thinner struts, enhanced radial strength, and biocompatible polymers – features that contribute to better deliverability, faster endothelialization, and reduced restenosis. Additionally, robust clinical evidence supports their use across a broad spectrum of lesion and patient types, including those with high bleeding risk or requiring shorter DAPT duration.
Conclusion
For physicians managing patients undergoing PCI, stent selection is not about choosing the latest innovation. It is about matching the device to the patient’s anatomy, risk profile, medication tolerance, and long-term care plan.
Whether deciding between drug-eluting stents vs bare-metal stents, assessing the need for polymer-free stents, or optimising procedural outcomes with imaging and post-dilation techniques in how to choose stent size, the decision must be personalised.
Current guidelines from ESC and ACC support the widespread use of second- generation DES with tailored DAPT duration. Where bleeding risk is high or compliance is uncertain, alternative devices with reduced therapy requirements can be considered.
With continual innovation and strong clinical data from trusted stent manufacturers, staying updated helps physicians make informed decisions.
In summary, the best stent is not defined by a product name but by its fit to the patient’s needs, the team’s procedural confidence, and the physician’s clinical judgement.
