Talk:Drug-eluting stent

Structure of this important piece

It would be valuable to maintain the credibility of this article, and prevent it turning into a battleground for highly polarized opinions, where editors stake out extreme positions ("CABG is superior to DES for two-vessel disease" -- NOT supported by the majority of clinical research nor by guidelines of the professional bodies) and inflammatory positions ("Legal status: As enthusiasm for these new devices abates...." -- has nothing to do with the "legal" status of the devices, either from a regulatory standpoint nor even from the POV of the plaintiffs' bar.)

It would be valuable to organize this in a rational way -- rather than jumping from history of balloon angioplasty, to pre-clinical investigational bioresorbable stents (in one edit, incorrectly headed as "drug elution"), to "alternative drugs", all before ever saying a word about the DES that are currently available for clinical use, and about which there are thousands of verifiable citations to substantiate a wiki article.

I have cleaned up the structure, written balanced positions on controversial topics, and attempted to restore a sense of decorum.

Nuff said. Debate welcomed here if someone disagrees with my edits. Donsmokem (talk) 01:41, 12 March 2008 (UTC)

I think the page is reasonable tidy enough now to remove the cleanup and advert / coi tags. I agree with the material in the edit by Donsmokem that was reverted at 00:40, March 12, 2008 by Orangemarlin. The Percutaneous coronary intervention and Coronary stent pages could use work too. History of balloon angioplasty shouldn't be included on this page, it should be on one of the parent pages (probably PCI). Dlodge (talk) 12:44, 12 March 2008 (UTC)

Marlin removed a particularly nice piece of the article under Alternatives:" Differences between outcomes with stenting and with coronary bypass grafting (CABG) are a point of controversy. Some studies suggest CABG is superior in multivessel (two or more diseased arteries) coronary artery disease (CAD) as regards a combined endpoint measure of death, myocardial infarction and repeat revascularization. Other studies, including the ARTS II registry, suggest that drug-eluting stenting is not inferior to coronary bypass for treatment of multivessel coronary disease. In all comparison studies of stenting vs. bypass surgery, it is worth noting that only a small minority of patients with multivessel coronary disease have been eligible for inclusion in the studies, and that for most patients, clinical judgement by experienced operators suggests that one or the other approach is preferred." To that end, I have included it above to ask, why exactly that was a bad section? I think it is fairly NPOV, maybe even leaning towards anti-stents given the lack of a citation on the pro-stents end, so why was that removed?Merechriolus (talk) 02:19, 13 March 2008 (UTC)

I added the deleted text back in modified form to balance the alternatives section - I didn't have time to look up the ARTS reference. There should also be some mention of medical management vs. DES here. Any objection to removing the COI / advert & cleanup tags? Dlodge (talk) 04:07, 13 March 2008 (UTC)

GA restructuring completed. BeingObjective (talk) 14:57, 24 November 2023 (UTC)

Orangemarlin continues to revert and delete every contribution I have made towards neutrality, verifiability, and expertise on the subject. The "legal status" piece is particularly devoid of value. Could someone please guide me towards an appeal process? Donsmokem (talk) 20:54, 14 March 2008 (UTC)

I think this revision of the piece restores the NPOV based on the consensus of Merechriolus and Dlodge. If there is a reason to revert and delete this work again, would the editor please address that reason here and attempt to shift consensus, rather than unilaterally making the change? Thank you. Donsmokem (talk) 02:09, 16 March 2008 (UTC)

This reads NPOV. BeingObjective (talk) 14:57, 24 November 2023 (UTC)

Orangemarlin re-applied the advert, clearup, and citation tags. Dlodge and I agree that they can be removed. Consensus? Donsmokem (talk) 03:12, 16 March 2008 (UTC)

And I will continue to do so. This piece is written by Cordis-JNJ. Why else would it be so POV. By the way, why would you think I'm not more or less as expert on this topic as you are? In fact, I can guarantee that I am not only more expert, I am probably one of THE most expert on this topic. Outside of this one article, which I only edit because I noticed so many Cordis IP addresses editing, I stay out of any Cardiology article specifically because I know too much and I would be too POV. Finally, and if you would care, I'm trying to create a WP:MEDMOS for articles on medical devices. A number of medical editors here wanted to use this as a sample article.

If you have a suggestion to create this article in a logical manner, then please go for it. You can read up on WP:MEDMOS which is a manner to standardize the article. For example Legal Issues is just a placeholder name. It can be regulatory, or anything else.

I want the tags to stay. On the other hand, you can find a way to make this article sound less like a JNJ advertisement, we can remove them.. That's all I'm asking.

I would ask that any further personal attacks against me end now. OrangeMarlin ^{Talk• Contributions} 03:26, 16 March 2008 (UTC)

NPOV.

No edit wars - after so many years- the article is considered stable. BeingObjective (talk) 14:59, 24 November 2023 (UTC)

No ad-hominem attacks here, orangefish. I'm sure you know something about the field. I do too, including as an editor of a high-impact journal in the field. I believe that it is free of pro-JNJ, pro-BSCI, pro-DES bias. If you could point to the word, words, lines, or concepts that sound to you like advertising, I am sure that the community of legitimate experts in the field will do something about it. Donsmokem (talk) 03:58, 16 March 2008 (UTC)

I don't edit medical articles with POV pushers and those who engage in personal attacks. Please enjoy your editing. OrangeMarlin ^{Talk• Contributions} 08:53, 16 March 2008 (UTC)

...though you could be helpful and point out the statement in question, because this has caught my interest too.Merechriolus (talk) 21:37, 16 March 2008 (UTC)

If no one else advocates for retaining the tags, then we ought to remove them. Donsmokem (talk) 12:30, 16 March 2008 (UTC)

I completely agree with the revisions that Dlodge made to the "Alternatives" section. The structure seems basically sound to me. The stent thrombosis issue could be 10 pages long if editors wanted to expand it, but I think it's factual and neutral now. Citations still need a little clean-up, then it ought to stand as a Good Article. Donsmokem (talk) 00:12, 17 March 2008 (UTC)

References

Good Article Nomination

The majority of this article is written/edited by BeingObjective, but he is permanently banned, therefore I would nominate the article, as I also substantially contributed to the article, see https://xtools.wmcloud.org/authorship/en.wikipedia.org/Drug-eluting%20stent/ -- Maxim Masiutin (talk) 09:50, 7 February 2024 (UTC)

GA Review

This review is transcluded from Talk:Drug-eluting stent/GA1. The edit link for this section can be used to add comments to the review.

Reviewer: NikosGouliaros (talk · contribs) 20:34, 7 March 2024 (UTC)

Thank you, looking forward for hearing from you soon! Maxim Masiutin (talk) 23:36, 7 March 2024 (UTC)

Our mutual replies were here and there and impossible for anyone other than us to follow, so I've arranged them in sections, keeping them time-stamped. Hope this helps.Please let's keep our replies in the section they are meant for. NikosGouliaros (talk) 21:56, 19 March 2024 (UTC)

General

Note that this is my first GA review; I am prepared to be corrected or withdraw if experienced editors believe I am off-base. Also note I am not a native English speaker.

There is no doubt a lot of work has been put to this article on a magnificent device, which performs two complicated functions together (vessel scaffolding and gradual drug emitting), and has been described as a "multidiscipllinary success story", so congratulations to its contributors. However, I humbly express my skepticism that it can be brought to GA status in the time frame of a GA review. In my opinion there are some gaps in the coverage of the topic, coupled with undue weight placed on peripheral aspects of it. For now, I am explaining my general thoughts on the article content, and then taking a closer look at the Lead, as an idea of what more detailed fact-checking, reference-checking and copy-editing could look like for the rest of it.

So, starting from the big picture: Drug eluting stent follows, to some extent, the Manual of Style on medicine-related articles as regards the article layout; there, medical devices are grouped with drugs and treatments, and I'd argue this isn't very helpful, as this layout is clearly made for medications. Crucially, it lacks a section on the description of the device, and the different types it comes in. One can compare similar GAs: The only Good Articles on a medical device are Dental implant, which has a "composition" section right after "uses"; and Injector pen, with a "design" section in the same place. Another instance of a somewhat similarly themed Good Article is Brachytherapy, which has a section on "types". (No Featured Articles with helpful thematic similarities are found). So, I think this article is definitely missing a section dedicated to describing the device (I expand on some potential ways of describing it later on), and its different subtypes. More specifically, this section could also mention:

• the materials it is made of (with a word on the role of polymers in drug delivery, and perhaps mentioning the corresponding stent types, including polymer-free stents, and bioresorbable stents)
• perhaps the word "struts", including some of the info currently in Research directions
• the actual pharmaceutical compounds they emit
• the fact that some DES (the majority) are balloon-expandable, but a few ones, including the very first one in 1986, are self-expanding,
• the distinction between coronary and peripheral stents.

I'd argue the section on description I'm proposing would be better suited after Uses (like in the aforementioned GAs), since Uses is the section that also gives background info on atherosclerosis and restenosis, two essential concepts to grasp what's behind DES design.

So, moving on to Uses: I think it needs a little more general background on atherosclerosis, without jumping directly to coronary artery disease; nonetheless, specific info on symptoms and signs (under the heading Clinical indications) feel a bit non-relevant to the article. Also, from this point on, the section feels like coming from an article on PCI, not DES. Importantly: but for a brief lead reference, the article ignores the use of drug eluting stents (DES) in peripheral arterial interventions, and only covers coronary interventions. It couldn't reasonably pass GA review without expanding its breadth of coverage to the role of DES in peripheral arterial disease, relatively limited though it is. The obvious place for this is probably [[Drug eluting stent#Uses]|this section].

The Clinical Procedure section is welcome; I wonder if being somewhat less detailed could help it. The section on Efficacy feels not necessary: much of it just repeats info already given, or that could reasonably fit elsewhere; on the other had, it could merge with Complications into an Outcomes section. I'm also skeptical on the role of Design considerations: it reads a bit like a foreword to a manufacturer's manual. The info including in the Alternatives section could either be missing or fit in Uses.

History is of course welcome, but I wonder if some of the material in the first three paragraphs could be shortened.

I am now thinking on how can I edit the lead to implement your suggestions. Maxim Masiutin (talk) 00:28, 16 March 2024 (UTC)

@NikosGouliaros, did my edits resolve your concerns? Should I do further edits if I didn't fix all your observations, or you have further concerns? By the way, according to WP:GAN/I#R3, in the case of a marginally non-compliant nomination, if the problems are easy to resolve, the reviewer may be bold and fix them immediately. The Good Article review is designed to be a lightweight process. Its primary goal is to assess whether an article meets the GA criteria, which cover the main aspects of article quality such as accuracy, neutrality, completeness, and style, but it does not require the article to be perfect. The reviewer checks the article against the GA criteria, focusing on aspects like verifiability, broad coverage, neutrality, stability, and good writing. There is always improvement opportunity: even after an article passes the GA review, it can still be improved. Editors are encouraged to continue refining articles to higher standards. In contrast, the Featured Article (FA) review is more rigorous: it involves a more thorough examination, and the criteria are more stringent, aiming for professional standards of writing, presentation, and sourcing. The FA process is intended to identify Wikipedia's very best work as examples for other articles to follow. Looking for your feedback. Maxim Masiutin (talk) 00:12, 19 March 2024 (UTC)

@Maxim Masiutin: Your edits are to the right direction, and this GA review looks like it can eventually end with a pass. It just takes some time to review and re-review. Thank you for your kind and well-meant responses, and also for your patience with my overzealous concerns. I'm trying to keep it simple and not more heavyweight than appropriate. NikosGouliaros (talk) 21:56, 19 March 2024 (UTC)

Lead

• As a whole, the lead could benefit from some editing: concepts and terms are introduced in non-optimal succession, and with repetitions. Examples thereof:
  • 1st paragraph: "It releases drugs to prevent the growth of scar tissue and reduce the risk of stent restenosis..."; followed by "A drug-eluting stent is different from other types of stents because it has a coating that delivers medication..."
  • "...can be inserted into blocked or narrowed arteries through a catheter placed in a peripheral artery"; followed, two paragraphs later, by "PCI uses larger peripheral arteries in the arms or the legs to thread a catheter..."
  • 3rd paragraph: " As of 2023, more than 90 percent of stents used in PCI procedures were DES."; followed, in the next paragraph, by "DES devices are a primary choice of interventional cardiologists and..."
  • 4th paragraph: "...superior to prior non-drug eluting or bare-metal stents", followed by "DES products hold an advantage over BMS offerings."
• First sentence: The word tube, on its own, brings to my mind the image of a continuous hose; The Concise Oxford Medical Dictionary does define a stent as 'a tube... [which] may be a simple tube, usually plastic, or an expandable, usually sprung mesh metal, tube'; however, vascular stents specifically are in mesh form; in other words, they are a tubular mesh. A great dscription of stents is "hollow cylinders, usually fabricated from metal meshes that are inserted in a collapsed state across a site of arterial blockage and stretched open by inflating an angioplasty balloon". Also, I'm not sure if the first sentence is successful in giving a concise idea of the stent concept. A great word for defining and describing stents is scaffold, as in "stents act as a scaffold on the inner arterial wall to prevent early and late vascular remodeling"; or a mechanical support device. Also, the first sentence has a pair of adjacent wikilinks; I think a more specific link to atherosclerosis solves the problem.
• "A DES is often made of metal alloys and can be inserted into blocked or narrowed arteries through a catheter placed in a peripheral artery, such as in the arm or leg. DES is fully integrated with a catheter delivery system and is viewed as one integrated medical device." Mentioning a "peripheral artery" as a catheter entrance site means clearly that the sentence speaks of coronary angioplasty. I'll expand later, but vascular stents aren't only used in coronary arteries, but also in peripheral ones, albeit much less commonly. In my mind, one needs to first speak of (and link to) angioplasty in general, and perhaps also of balloons and then of coronary angioplasty. Otherwise, it's a short of hysteron proteron.
• "Drug-eluting stents in current use were approved by the FDA after clinical trials demonstrated...": Mentioning FDA in the lead is unnecessary, and against global perspective.
• "There is significant clinical data relating to the use and outcomes of DES, general stents, PCI and coronary artery bypass graft (CABG) surgery." This sentence seems written for the article on coronary artery disease, or revascularization, not DES.
• Lead references:
  • All three citations at the end of the first paragraph are of low quality (a news article from a medical journal and two industry websites), and are redundant.
  • "As of 2023, more than 90 percent of stents used in PCI procedures were DES." This fact, which isn't mentioned in the main body of the article, is not supported by the cited reference. I'm not saying it's wrong: "B[are]M[etal]S[tent]s are currently used in 10% to 20% of patients undergoing PCI.
  • Citation 6 is a primary source, so also has no point in the lead section. There are more recent, secondary sources on the superiority of DES over BMS.
  • Citations 8-10 are from controversial or non-Pubmed-indexed journals.

These are some first thoughts. Looking forward to some reaction! NikosGouliaros (talk) 21:04, 8 March 2024 (UTC)

Thank you, please let me resolve all your concerns in 1-2 days. Maxim Masiutin (talk) 21:14, 8 March 2024 (UTC)

Please be aware that the the list criteria for the article to be GA is short and exhaustive, the reviewers should not impose as mandatory . additional requirements beyound what is specified in the GA criteria. Suggestions that exceed GA criteria are always welcome, but they should not serve grounds as specifying the "Fail" result. Besides that, you can also help other people to help via Wikipedia talk:Good article nominations. I saw you made a post in the Wikiproject Medicine, which is good, however, I found out that the people in Wikipedia talk:Good article nominations are much more responsive than those in the Wikiproject Medicine.

I'm now working on your objections, please let me resolve them. Maxim Masiutin (talk) 04:30, 10 March 2024 (UTC)

I indeed used a Petscan tools to look for the articles in the "Implants (medicine)" category that also have "Good articles" or "Featured articles" category. There was indeed only Dental implant in both "Implants (medicine)" and "Good articles" category, and there were no "Features articles" that were also present in the "Implants (medicine)" category. I have a suspicion that there are articles about implants that were not included formally into the "Implants (medicine)" category, that's why we can't find any. Maxim Masiutin (talk) 20:18, 10 March 2024 (UTC)

Upon your review, I made the correction: the article tells that the tube made of a mesh-like material. Is that OK? Or we should something? My email and access works properly, sometimes errror happen when qn editor' is turned off.Please let me now there I can payfo r it? Maxim Masiutin (talk) 20:39, 10 March 2024 (UTC)

I am sorry that I wasn't able to finish addressing all your issues in 1-2 days. If you have time, can you please mark the review on hold for 5 more days, so I will finish by that time, otherwise, ff you would like to finish the review quickly, can you please conclude the review as "Fail", after that I will improve the article and re-nominate them again? I will also discuss in the Wikiproject Medicine how to deal with medical devices and/or implants. Maxim Masiutin (talk) 10:26, 11 March 2024 (UTC)

Sure, no rush. I need time to review the changes myself, though they seem to the right direction! NikosGouliaros (talk) 21:07, 11 March 2024 (UTC)

So, the canges are definitely in the right direction, but the ones in the lead somewhat less so than the rest. In the lead, and especially in the first paragraph, the reader is not eased perfectly smoothly into the subject. Repetitions seem to still be a problem:; for example: The stent slowly releases a drug to prevent re-blockage of the artery is followed by The release of the drug from the stent to prevent the growth of scar tissue and reduce the risk of stent restenosis, which is the narrowing of the stented area of an artery after treatment: this repeats less than it expands on the previous sentence, but the first paragraph of the lead might not be the perfect place for expanding; directly follows A drug-eluting stent is different from other types of stents because it has a coating that delivers medication directly to the arterial wall., which is saying pretty much the same. Moreover, the first paragraph describes the stent insertion procedure, before the reader becomes acquainted with the concept of atherosclerosis and perhaps angioplasty.

Now, I do wonder if I'm imposing personal preferences or arbitrary stylistic ideas as I'm reviewing the prose quality of the lead. But do you think you could re-edit it a bit, with the above in mind, and we can decide together if the product works better?

Thoughts? NikosGouliaros (talk) 20:25, 14 March 2024 (UTC)

I reworked the lead section, based on your observation. I made it more straightforward, shorter and more intelligible, removing the repetition and improving the information flow. I made the lead consists of 3 sections: introduction, on drug release and on application/PCI.

Please let me know whether I should improve the lead further.

Let us finish with the lead before we can proceed to the other sections. Maxim Masiutin (talk) 22:04, 16 March 2024 (UTC)

I finished work on the lead yesterday, I hope I have fixed all your concerns about the lead. I also removed the "Summary" sub-title from the "Design" sections. Overall, I hope that I have addressed all the concerns that you gave here. Maxim Masiutin (talk) 14:58, 17 March 2024 (UTC)

Thanks for heeding my suggestions and of course for your work. Making the lead more compact has greatly helped! I'll go ahead and myself make some mostly factual corrections (described in their edit summaries - we can discuss any of them). This honestly looks good; I still have some misgivings on the references though: A GA, and a lead, doesn't need to be perfectly cited; I will only insist on a reference for the fact that As of 2023, more than 90 percent of stents used in PCI procedures were DES, as I can't find where the source mentions this, and it is a challengeable piece of info. NikosGouliaros (talk) 22:33, 17 March 2024 (UTC)

Thank you very much for pointing out unsourced information at the lead about the percentage figures (90%) in 2023. I removed the unsourced information from the lead about the year 2023, and put the percentage use into the history section, as the data was in fact from 2005-2006, not 2023. This data about 2005 may be of historical intereste, but it is no longer relevant in the lead.

I also put appropriate sources to the lead on multiple DES use on a single patient, and copied this data from the lead to the body, putting appropriate sources for that. Maxim Masiutin (talk) 23:23, 17 March 2024 (UTC)

Thank you, please fix the information as you wish, I'd be grateful.

You wrote that per GA the lead should not be fully cited, however, in this case, there should be that information duplicated in the body where it should be cited and this information should be easy to find. Maxim Masiutin (talk) 23:38, 17 March 2024 (UTC)

Design

I added the "Design" section that briefly covers the issues that you've raised. Maxim Masiutin (talk) 17:40, 11 March 2024 (UTC)

The section on design is a very very welcome addition. Its coverage of the main aspects of stent design is very good. Do you think the subsection titled "Summary" is necessary? It feels as if written for a stent-design manual; and the title is obviously inappropriate. NikosGouliaros (talk) 20:25, 14 March 2024 (UTC)

In Uses Design, I do believe the whole section previously titled "Summary" (from In designing a DES to add further complexity to design considerations), and not just the heading, should go; it is somewhat manual-like, it repeats already given info, and it feels a bit in violation of GA criterion 3b. But I'm willing to be convinced differently.

Getting back on the rest of the sections! NikosGouliaros (talk) 22:33, 17 March 2024 (UTC)

Please also let me delete or rewrite the information from "In designing a DES" to "add further complexity to design considerations", let me think on how should I fix it. Maxim Masiutin (talk) 23:24, 17 March 2024 (UTC)

I rewritten the paragraph in the Design section, the new paragraph starts with "DES is a sophisticated medical device with several key properties". Please let me know whether this style is OK, or I should improve/fix it, or delete such paragraph altogether. Maxim Masiutin (talk) 23:36, 17 March 2024 (UTC)

I also rearranged the material in the "Design" section for logical flow. Maxim Masiutin (talk) 08:15, 19 March 2024 (UTC)

@Maxim Masiutin: As it is, the design section is definitely good. I'm only making a minor clarification on peripheral DESs. Also, give me some time to check some of the sources. NikosGouliaros (talk) 21:56, 19 March 2024 (UTC)

Uses

The first paragraph in Uses is so much better!NikosGouliaros (talk) 20:25, 14 March 2024 (UTC)

I added information on both coronary stents and peripheral stents, in the uses section, and also added some background on atherosclerosis. Maxim Masiutin (talk) 00:27, 16 March 2024 (UTC)

Notes

References

Follow-up questions

Hello, NikosGouliaros! I hope I resolved your concerns and objections one week ago. Do you have any more concerns that I have to address? Are you expecting any action for me for these last 5-7 days? Please let me know how should I proceed. Maxim Masiutin (talk) 20:39, 25 March 2024 (UTC)

The reviewer abandoned this nomination. ~~ AirshipJungleman29 (talk) 17:35, 7 April 2024 (UTC)