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Page 8 of 17 Arisha et al. Vessel Plus 2018;2:14 I http://dx.doi.org/10.20517/2574-1209.2018.29

both approaches [41,68] , however, many investigators believe that older population can benefit more from the
transradial approach and it should be used more often with the elderly undergoing PCI.

TYPE OF STENT
As it was discussed above, the coronary lesions in the elderly tend to be more complex and extensive which
may render them suitable only for plain old balloon angioplasty (POBA) due to a failure of stent delivery,
or inability to stent lesions in distal or small diameter vessels . On the other hand, stenting technology
[43]
has revolutionized during the last era. Since their first successful clinical application in 2002, drug-eluting
stents (DES) have been utilized more frequently comparing to bare metal stents (BMS) as lower rates of stent
restenosis, major adverse cardiac events, and revascularization of target lesions have all been associated with
the use of DES . The second-generation DES even have a better stent design than the first-generation ones with
[69]
a thinner strut and more biocompatible polymers which lead to a higher efficacy and lower complications [70,71] .
However, the use DAPT for at least 1 year to prevent stent thrombosis associated with DES raises concerns
regarding increased risk of bleeding especially in populations with an already high risk of bleeding such as
the elderly . Although some studies suggested reducing the DAPT to 3-6 months without an increase in the
[70]
risk of many adverse clinical events . Recent data still suggesting under-utilization of DES in elderly patients
[72]
undergoing PCI with stenting . The characteristics and clinical outcomes of 1564 high bleeding risk old
[70]
patients aged 75 years or older who participated in the LEADERS FREE trial and underwent PCI with the
deployment of either polymer-free DES or similar BMS and only 1 month of DAPT were analyzed [73,74] . They
showed a high yet similar bleeding rate in the 2 groups. However, rates of mortality, stent thrombosis, MI, and
target lesion revascularization were lower in patients underwent stenting with DES reflecting superior safety
and efficacy benefits compared to BMS . In addition to that, major bleeding rates did not differ significantly
[74]
between octogenarian patients who received PCI with BMS and only 1-month mandatory DAPT and others
with DES and a 1-year course of DAPT in the XIMA trial . Also, compared to the first-generation DES, the
[75]
use of second-generation DES has been associated with better outcomes in the older population, as the latter
has been associated with a lower risk of MI in the following year among patients aged 70 years or older with a
hazard ratio of 0.40 (95% CI: 0.19-0.82); P = 0.012 . Most recently, the SENIOR trial demonstrated lower rates
[58]
of the 1-year all-cause mortality, MI, stroke, and revascularization in elderly patients who underwent PCI and
received third-generation DES with bioabsorbable polymer and a short-term DAPT compared to those who
received BMS . In the same trial, the duration of DAPT was decided before patients’ random assignment to
[76]
the two different types of stents and it was recommended to be 1 month for stable patients and 6 months for
unstable ones, however, the bleeding complications were comparable in both study arms.

BLEEDING AVOIDANCE STRATEGIES
With peri-procedural bleeding being one of the most concerning topics regarding PCI in elderly patients ,
[23]
several approaches and strategies have been developing aiming at reducing the amount of blood loss and
improving the safety and efficacy of these procedures in populations of high risk. Bleeding avoidance strategies
(BAS) include the usage of vascular closure devices (VCD), transradial approach instead of the transfemoral, and
bivalirudin instead of heparin and GP IIb/IIIa inhibitor . Previous data showed that BAS have been associated
[77]
with lower risk of Peri-PCI bleeding, nevertheless, these strategies are underutilized among patients with higher
risk of bleeding suggesting what we call “risk-treatment paradox” [77,78] . Khambatta et al. evaluated the data of
[79]
124,606 patients with different ages who underwent PCI over a period over 4 years to study the effect of BAS
on rates of bleeding and other variables in different age groups. They have demonstrated a lower incidence of
bleeding with the utilization of BAS with an adjusted odds ratio of 0.982 (95% CI: 0.980-0.984) compared to
those without BAS usage in all age groups even patients older than 80 years. BAS was also associated with lower
in-hospital mortality with an adjusted odds ratio of 0.993 (95% CI: 0.992-0.994). Interestingly, although the
overall usage of BAS has been improving in all age groups over the whole study period, their utilization was
still less frequent in old age patients .
[79]