Polymer-free dual drug-eluting stents evaluated in a porcine model

Coronary heart disease is one of the leading causes of mortality and morbidity worldwide. Noninvasive percutaneous coronary intervention (PCI) with stenting has become the standard of care, but delayed endothelialization and chronic inflammation caused by the polymer and the metal scaffolds lead to the development of stent restenosis (SR) and stent thrombosis (ST), the most important clinical problems following PCI. In an effort to decrease the incidence and consequences of these complications, bioresorbable coronary scaffolds have been developed albeit their use did not further improve short-term outcomes [1, 2].Polymer-free dual drug-eluting stents (DDES) may be a more effective approach.

Sirolimus (rapamycin) and its derivatives are still the most used antiproliferative agents in contemporary drug-eluting stents despite the fact they are associated with delayed endothelialization of the stents because of the inhibition of endothelial cell (EC) and endothelial progenitor cell (EPC) proliferation and differentiation [3, 4]. Indeed, autopsy studies have shown that the best morphometric predictor of late ST was the ratio of uncovered struts relative to the total stent struts, which is a marker of stent endothelialization [5]. Probucol is not only a potent antioxidant and lipid-lowering drug, it is also effective in reducing the risk of restenosis and the incidence of major adverse cardiac events after PCI [6]. Indeed, several studies, both in animals and humans, have shown some improvement in the rate of endothelialization of the stented arteries by probucol [7–9]. However, few preclinical studies have focused on the endothelialization of stented arteries associated with novel polymer-free DDESs. Consequently, the aim of the present study was to evaluate the efficacy and safety of the polymer-free stent-based delivery system of probucol alone compared with rapamycin, and probucol in combination with rapamycin in a porcine model of coronary artery stenting.

A total of 160 stents were successfully implanted in the coronary arteries of 80 pigs. Overall, 7 animals died during the course of the study; 2 of respiratory failure (1 in the 14-day group and 1 in the 28-day group) which was most likely due to the anesthesia, 3 of post-operative puncture site bleeding (2 in the 28-day group and 1 in the 90-day group), 1 of pneumonia (at 71 days follow-up) and 1 of ileus (at 180 days follow-up). None of the animals showed any evidence of ST or myocardial infarction. The latter 2 animals were included in the histological analysis. All other animals survived the intended study follow-up period without any angiographic ST or clinical complications. Stents distribution included in the analysis was showed in Table 1.

Quantitative coronary angiography evaluation

From baseline, the RVD, expansion ratio and the LL remained similar among the groups at all the four endpoints (Fig. 1 and Table 2).

		RVD (mm)	P	ER	P	LL (mm)	P	DS%	P
14 day
	BMS (n = 9)	2.60 ± 0.22	0.061	1.13 ± 0.14	0.067	0.32 ± 0.11	0.655	12.43 ± 4.50	0.429
	PrES (n = 10)	2.41 ± 0.31		1.25 ± 0.17		0.43 ± 0.29		19.12 ± 14.87
	SES (n = 9)	2.62 ± 0.28		1.17 ± 0.08		0.34 ± 0.21		12.99 ± 7.61
	DDES(n = 10)	2.36 ± 0.16		1.27 ± 0.09		0.36 ± 0.18		15.46 ± 8.07
28 day
	BMS (n = 8)	2.55 ± 0.39	0.994	1.19 ± 0.19	0.946	0.41 ± 0.39	0.409	18.26 ± 20.64	0.365
	PrES (n = 8)	2.56 ± 0.31		1.16 ± 0.09		0.28 ± 0.21		10.34 ± 6.93
	SES (n = 8)	2.55 ± 0.19		1.18 ± 0.12		0.18 ± 0.15		6.94 ± 5.76
	DDES(n = 8)	2.52 ± 0.38		1.20 ± 0.14		0.37 ± 0.32		15.90 ± 15.14
90 day
	BMS (n = 8)	2.37 ± 0.30	0.945	1.26 ± 0.13	0.662	0.76 ± 0.36	0.767	32.71 ± 16.40	0.809
	PrES (n = 8)	2.30 ± 0.22		1.29 ± 0.08		0.85 ± 0.44		37.19 ± 18.71
	SES (n = 8)	2.30 ± 0.27		1.29 ± 0.10		0.83 ± 0.34		35.45 ± 15.47
	DDES(n = 8)	2.34 ± 0.18		1.24 ± 0.10		0.96 ± 0.35		41.66 ± 15.79
191 day
	BMS (n = 9)	2.41 ± 0.30	0.335	1.28 ± 0.16	0.368	0.34 ± 0.31	0.079	15.76 ± 16.68	0.811
	PrES (n = 9)	2.31 ± 0.29		1.24 ± 0.14		0.62 ± 0.34		27.44 ± 16.22
	SES (n = 9)	2.31 ± 0.19		1.30 ± 0.10		0.41 ± 0.25		18.01 ± 11.28
	DDES(n = 9)	2.52 ± 0.31		1.19 ± 0.11		0.72 ± 0.36		29.70 ± 15.11

RVD reference vessel diameter, ER expansion ratio, LL lumen loss, DS% diameter stenosis %, BMS Bare-Metal Stents, PrES Probucol-Eluting Stents, SES Sirolimus-Eluting Stents, DDES Dual Drug-Eluting Stents

Optical coherence tomography evaluation

At 14- and 28-day time points, there were no significant differences in the NA between the four groups (Fig. 2a,b and Table 3), with no obvious ST, stent malapposition, dissection or prolapsed. At the 14-day time point, there was significant difference in the CSR between the four groups (p = 0.011), the CSR in the PrES group was greater than in SES group (53.2%, interquartile: 39.0% -81.0% vs. 20.3%, interquartile: 13.5% -26.0%, p = 0.002) (Fig. 2c and Table 3). However, a similar tendency was not observed at the 28-day time point.

		NA (mm2)	P	CSR%	P
14 day
	BMS (n = 8)	1.46 (1.35,1.69)	0.708	37.67 (26.74,50.65)	0.011
	PrES (n = 9)	1.56 (1.35,1.88)		53.24 (38.99,81.05)
	SES (n = 7)	1.52 (1.16,1.61)		20.27 (13.49,25.95)
	DDES(n = 8)	1.38 (1.34,1.56)		40.06 (14.12,50.16)
28 day
	BMS (n = 7)	2.57 (1.75,2.98)	0.300	93.64 (89.07,97.79)	0.644
	PrES (n = 7)	2.23 (1.57,3.15)		92.77 (50.00,98.23)
	SES (n = 7)	1.91 (1.49,2.30)		85.15 (84.94,100.00)
	DDES(n = 6)	1.68 (1.54,2.40)		88.22 (64.24,94.56)

NA Neointimal Area, CSR% Ratio of Covered Struts, BMS Bare-Metal Stents, PrES Probucol-Eluting Stents, SES Sirolimus-Eluting Stents, DDES Dual Drug-Eluting Stents

Histology evaluation

At the four time points, there were no significant differences in the NA, and injury, inflammation and endothelialization scores between the four groups (Fig. 3).

Scanning electron microscope evaluation

At the 14- and 28-day time points, the rate of covered struts was observed at low magnification and the rate of covered struts by endothelial cells was observed at high magnification. The former was ranked as PrES > DDES > BMS > SES, and the latter was ranked as PrES > BMS > DDES > SES at 14 days (Fig. 4a). At 28 days, the rate of covered struts observed at low magnification was ranked as BMS > SES > PrES > DDES, while it was ranked as PrES > DDES > SES > BMS at high magnification (Fig. 4b).

Western blot and real time polymerase chain reaction

At the four time points, there were no significant differences in the expression of CD31, CD34 and CD133 between the four groups in terms of mRNA (Fig. 5) and protein level (Fig. 6).

Improvements in metal scaffolds, polymers and antiproliferative drugs of second generation DES have resulted in increased biocompatibility. However, they are still associated with a high incidence of SR and ST and, although polymer-free DES has been shown to be safe and efficacious in both animals [13–15] and humans [16–21], they are not routinely used in contemporary clinical practice. Animals study can effectively evaluate the safety of stents, but not their effectiveness. Clinical trials conducted over the past years were not large enough and lacked control groups to conclusively demonstrate the efficacy of polymer-free DES. Because of this, interventional cardiologists are often reluctant to use them despite their potential benefits. There are a few studies that have demonstrated that the antiproliferative drugs contained in the polymers could theoretically be lost in the process of transportation and release, reducing their long-term safety and short-term effectiveness. A coating of rapamycin or its derivatives on the surface of stents greatly reduces the rate of SR and target vessel revascularization, but not the occurrence of ST, especially late events. Because delayed endothelialization is believe to play a key role in the occurrence of late ST, research has attempted to improve the stent platform and the drug loading as well as drugs that may improve stent endothelialization by virtue of their antioxidant and anti-inflammatory properties. Probucol is such a drug, and several large clinical studies showed the non-inferiority of the polymer-free probucol/rapamycin DDES compared with the first and second generation polymer-based DES on the efficacy and safety [22–24]. However, a multi-center clinical study conducted in China showed that the same stent was associated with a higher incidence of restenosis and target vessels revascularization than the biodegradable polymer DES used as controls [25]. On the other hand, an animal study showed that succinobucol (a probucol analogue) eluting stents significantly increased the neointimal area of the stented vessel segment compared with rapamycin-eluting stents [26]. Thus, the efficacy and safety of this type of stent need to be further evaluated. The goal of the present study was to evaluate the safety of this novel DDES using a porcine model of coronary stenting. As well, we also evaluated whether the DDES could improve stent endothelialization.

Results of our study show that, irrespective of stent type, all animals had similar expansion ratio and injury scores at each time points, reflecting comparable vessel injury. Also, the lumen loss evaluated by QCA, the neointimal area evaluated by OCT and the histomorphology analysis assessing the neointimal proliferation level of the stented vessel segment were similar between all animals at all time points. On the one hand, our results show that the novel DDES has a similar anti-proliferative capability with the commercially available SES. However, the SES and DDES groups showed a similar anti-proliferative capability with the BMS group in each time point. This result may be due to the small sample size of each group.

Delayed endothelialization is considered to be a major underlying mechanism of ST, and numerous studies have evaluated the strut coverage level as a measure of reendothelialization. However, it is important to note that the struts that were completely covered did not represent the EC covering the entire lumen. These OCT studies could not distinguish if the coverage of the stent struts was by EC or other cell type. The coverage might not have the functionality of EC, especially its anti-thrombotic property [27]. Although some study has suggested that the strut coverage level might be associated with endothelial function [28], the evidence presented is unclear.

Our OCT results show that, at the 14-day time point, the strut coverage percentage in the PrES group was significantly higher than that observed in the SES group. Also, it had the highest percentage of EC coverage under SEM. However, such difference did not translate into mRNA and protein expression. At the 28-day time point, there was no significant difference between the groups with respect to strut coverage percentage, but it seemed to be higher in the BMS group than in the other groups, as observed by SEM. At high magnification, it compared with the PrES group, although the struts were almost completely covered in the BMS group with large part of the covering being only a layer of extracellular matrix, not EC (Fig. 4c). Conversely, although the struts were incompletely covered in the PrES group, the majority of the covering was by EC (Fig. 4d). There was also no obvious connection between the strut coverage observed by OCT and EC coverage assessed by HE staining at high magnification (Fig. 7).

There was no significant difference in the expression of both EC marker CD31 and EPC markers CD34 and CD133 in the mRNA and protein level between groups at all the four time points. In the histopathological analysis, there was also no significant difference in the endothelialization scores between groups at all the four time points. Overall, our results suggest that the local release of rapamycin at low concentration used in the SES and DDES groups did not significantly reduce the local expression of EC and EPC. These results are in agreement with those of previous in vitro studies [29, 30].

Although rapamycin can inhibit the differentiation, proliferation, migration, adhesion and endothelial nitric oxide synthase expression of EPC [31], its effect on the homing of EPC at the site of the stented vessel segment might be different from previous studies. Also, the local release of probucol in the PrES and DDES groups showed a tendency to improve the short-term endothelialization when compared with the other groups in qualitative SEM analysis, although it was not detected in mRNA and protein level. Small sample sizes and the sampling method of the stented segments might have played a role. Lastly, at the time points of 90 and 180 days, obvious angiogenesis in the neointima was occasionally observed, resulting in individual higher injury scores as assessed by HE staining (Fig. 8). Although this phenomenon has never been reported in similar animal models, it is relatively common in studies of atherosclerotic plaques and in-stent neoatherosclerotic lesions [32, 33] and is often associated with late adverse events. In the present study, the development of this phenomenon interfered with the detection of the marker of endothelialization, likely due to the overlapping of endothelial cells and EPC at the lumen surface and angiogenesis. Consequently, this phenomenon could allow researchers to use this model for unstable atherosclerotic lesions and in-stent neoatherosclerotic lesions.

Polymer-free dual drug-eluting stents are as safe as the commercially available BMS and SES, but they do not result in further improvement of the endothelialization of the stented porcine coronary arteries.