Impact of total stent length on long-term outcomes with different newer-generation drug-eluting stent designs in ST-segment elevation myocardial infarction: A subgroup analysis from the BIOSTEMI ES randomized trial

Background Longer total stent length (TSL) increases the risk of target lesion failure (TLF) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES). We aimed to assess the long-term impact of TSL on patient- and stent-related outcomes in STEMI patients treated with different newer-generation DES designs. Methods We performed a post hoc subgroup analysis of the BIOSTEMI Extended Survival randomized trial (NCT05484310). Patients undergoing primary PCI for STEMI were randomized to ultrathin-strut biodegradable-polymer sirolimus-eluting stents (BP-SES) or thin-strut durable-polymer everolimus-eluting stents (DP-EES) and categorized according to TSL implanted at the culprit site (≤40 mm vs. >40 mm). The device-oriented composite endpoint (TLF) was the composite of cardiac death, target-vessel (TV) myocardial reinfarction, or clinically indicated target lesion revascularization (TLR), and the patient-oriented composite endpoint (POCE) was the composite of all-cause death, any myocardial reinfarction, any revascularization, or any stroke, at 5 years. Results A total of 1,686 STEMI patients were included (mean age, 62.4 years; female, 23%; mean TSL, 33.8 mm), of whom 423 (25%) were treated with TSL >40 mm. At 5 years, TSL >40 mm was associated with a significantly higher risk of POCE compared with TSL ≤40 mm [31.7% vs. 27.4%; hazard ratio (HR), 1.30; 95% confidence interval (CI), 1.03-1.64; p=0.029], whereas no difference was observed in TLF. However, there was a significant interaction between DES type and TSL for TLF at 5 years. Among patients with TSL >40 mm, BP-SES were associated with a lower risk of TLF compared with DP-EES (7.3% vs. 17.1%; HR, 0.39; 95% CI, 0.21-0.74; p=0.004; p for interaction=0.032), a difference primarily driven by a lower rate of target vessel myocardial reinfarction. No significant differences between BP-SES and DP-EES were observed in patients with TSL ≤40 mm. After adjustment for multivessel treatment, increasing TSL with DP-EES, but not BP-SES, was independently associated with a higher risk of TLF (adjusted HR per 5-mm increase, 1.07; 95% CI, 1.02-1.11; p=0.003). Conclusion In STEMI patients treated with contemporary DES, TSL >40 mm was associated with an increased risk of patient-oriented, but not device-related, adverse outcomes at 5 years. Among patients requiring TSL >40 mm, ultrathin-strut BP-SES significantly reduced the risk of TLF compared with DP-EES, whereas no between-DES differences were observed in patients treated with TSL ≤40 mm.