Impact of Overlapping Heterogeneous Versus Homogeneous Drug-Eluting Stents on Clinical Outcomes: Should They Be Identical?

Background: Stent overlapping serves as a crucial strategy in achieving complete coverage of diffuse coronary artery lesions, plaque shifts, and edge dissections. Objectives: We aimed to evaluate the long-term clinical outcomes of overlapping heterogeneous drug-eluting stents (DES) in comparison to homogeneous DES. Methods: A total of 421 patients treated with overlapping DES were included in the study. The study patients were stratified into two groups according to the type of overlap: homogeneous (same antiproliferative drug and stent platform) and heterogeneous (different drug and/or platform). The primary endpoint was a device-oriented composite of cardiac death, target-vessel myocardial infarction and target lesion revascularization; a broader composite of all-cause death, any repeat revascularization, stent thrombosis, in-stent restenosis and cerebrovascular events (MACE) and its components were secondary endpoints. Propensity-score analysis with inverse probability of treatment weighting (IPTW) was used to account for treatment-selection bias. Results: The device-oriented composite endpoint occurred in 9.3% and 7.1% (p = 0.60), and MACE in 17.6% and 14.7% (p = 0.56) of patients with homogeneous and heterogeneous DES, respectively, with no significant difference in any individual component. After IPTW adjustment, heterogeneous overlap was not associated with an increased risk of MACE (odds ratio: 0.45, 95% confidence interval: 0.23–0.86) or of the device-oriented composite endpoint (0.52, 0.22–1.23). In a multivariable model with clinically prespecified covariates, lower left ventricular ejection fraction and greater total stent length, but not HbA1c, were independently associated with MACE. Conclusions: In this retrospective cohort, overlapping heterogeneous DES was not associated with an increased risk of adverse events compared with homogeneous DES, including in patients presenting with acute coronary syndromes; however, the modest sample size and the low number of events preclude conclusions of equivalence, and clinically relevant differences cannot be excluded.