Bosiers et al dual antiplatelet therapy and should temper nonchalant use of DES (Levy et al 2004; Moreno et al 2005). Unlike in animal models, use of DES in human atherosclerotic arteries results in delayed endothelialazation around the stent struts and thus makes the stent more susceptible to thrombosis. In coronary DES trials, the increased incidence of thrombosis with DES is small, in the order of 0.6% per annum, but, the accompanying 31%–45% mortality rate from the resultant myocardial infarction is of great concern (Harper 2004). Despite the fact that DES thrombosis in the peripheral circulation is not as lethal as in coronaries, dual antiplatelet therapy after DES is also warranted for PAOD to guarantee optimal stent performance and patient clinical well-being. Nevertheless, the use of dual antiplatelet therapy is related with an increased incidence (1%–2% per annum) of major bleeding complications and is expensive (Diener et al 2004; Eisenstein et al 2007). One year of clopidogrel costs approximately US$1000.00. This expense is in addi- tion to the cost already incurred by using a DES, which is usually fourfold greater than the bare metal equivalent; one coronary BMS costs US$800.00 while one DES costs up to US$2500.00 (Harper 2004). The duration of treatment with dual antiplatelet therapy after both coronary and peripheral implantation of DES remains a subject of ongoing debate. Based on emerging evidence, many cardiologists are recom- mending a minimum of 12 months of aspirin and clopidogrel, but, some are advocating indeﬁnite use of dual antiplatelet therapy after DES implantation (Waksman 2006). To overcome some of the shortcomings of the current gen- eration of DES, further modiﬁcations in already existing stent technology need to be pursued, especially for infrapopliteal interventions. As CLI patients most often present with long, diffuse BK lesions, longer stents need to be manufactured to make use of DES more cost-effective in the BK vasculature. Especially for these longer lesions, there might be need for the development of speciﬁc infrapopliteal, drug-eluting, self-expanding nitinol stents to help circumvent potential crushing and strut fractures seen with the balloon-expandable platform (Scharzmaier-D’Assie et al 2007). One option involves development of drug-eluting bioabsorbable stents (Waksman 2006). The limitation of bioabsorbable stents has been the inﬂammatory response that is elicited after implan- tation. Modiﬁcation of this response through local elution of anti-inﬂammatory, antiproliferative drugs should minimize restenosis, as well as inhibit injury-induced neointimal hyper- plasia. As the requirement for vessel scaffolding provided by the stent is only needed temporarily, subsequent absorp- tion of the stent should, in turn, allow endothelialazation, 558 thus, precluding the need for ongoing antiplatelet therapy. (Waksman 2006) Another approach involves development of stents with inherent antithrombotic properties, such as stents coated with monoclonal antibodies capable of capturing cir- culating endothelial progenitor cells. (Harper 2004). Conclusion At present, the use of DES for noncoronary applications is investigational. Although there are good indications and some publications supporting the use of DES in several noncoronary vascular beds, more data and long-term follow- up are needed. The results from nonrandomized, controlled trials such as the ZILVER® PTX™ and STRIDES trials are eagerly anticipated, but, ultimately, randomized controlled trials comparing DES with BMS implantation need to be performed to determine DES superiority. Until these results are available, review of the literature prompts us to make the following recommendations: 1. DES in the SFA provide no added beneﬁt to the current generation of nitinol BMS, except, in complex lesions (long stenoses or occlusions). Additionally, in these type of complex lesions it will need to be investigated whether the potential improved patency and quality adjusted life year (QALY), outweigh the increased cost of (multiple) DES and the need for prolonged dual-antiplatelet therapy. 2. DES in the infrapopliteal vasculature of patients with CLI have the greatest potential beneﬁt because the one- year restenosis after implantation of BMS stents in this location is high (50%) (Bosiers et al 2006). From a ﬁnan- cial standpoint, there is existing coronary drug-eluting technology that can also be used in the infrapopliteal vasculature thus making this a more cost-effective under- taking. Preliminary results using DES in the infrapopliteal vasculature from single center studies are encouraging with low amputation rates ( 5% vs 50% for untreated patients with CLI) (Siablis et al 2005; Bosiers et al 2006; Commeau et al 2006). There is need for RCTs and there are plans to perform these in conjuction with industry. 3. DES in renal interventions provides no added beneﬁt to the current generation of balloon-expandable stents, except potentially in patients with solitary functional kidneys, where treatment failure has more compelling implica- tions, or in patients with small renal arteries ( 5 mm) where outcomes are less favourable. Conﬁrmation with RCTs is required. 4. Due to lack of evidence, DES in the intracranial and extracranial cerebrovascular vasculature is currently not supported. Vascular Health and Risk Management 2008:4(3)