Off-label indications for bioresorbable scaffolds: “Beethoven can, but you cannot”

The pianist Carl Czerny, a pupil of Beethoven, reports in his book On the Proper Performance of all Beethoven’s Works for the Piano an interesting anecdote. The young Anton Halm presented the master a sonata that he had just composed. Beethoven looked through it without finding anything that aroused his attention and after a few minutes gave the young composer his piece back, remarking that he had contravened several elementary rules of harmony. The young Halm protested: “But Beethoven himself also infringes the same rules of harmony!” Then the genius turned to him with a fulminating glance and declared: “Beethoven can, but you cannot”.
We should remember this motto whenever we consider off-label indications for novel devices or novel therapeutic options in general: “Beethoven can, but WE cannot”. The excess of self-assurance and overconfidence in our own capabilities is most likely behind the poorer-than-expected clinical performance of bioresorbable scaffolds (BRS) after becoming widely available [1], at variance with the outstanding promising results reported in pilot studies [2–4]. Therefore putting ourselves in the pupil’s shoes is always the advisable starting point to face an off-label indication for BRS.
Nonetheless, potential off-label indications pop up daily in our routine clinical practice, and we are compelled to explore them if we aim to optimise the treatment of our patients and the potential of the emerging technology. The motto “Beethoven can, but you cannot” is the best possible starting point, but it can never become an excuse to brake the expansion of novel therapeutic tools into more challenging scenarios, in which they may also be convenient and useful. In a recent number of Advances in Interventional Cardiology, our colleagues from Katowice, namely Roleder T, Wanha W, Smolka G, Zimoch J, Ochała A and Wojakowski W publish a modest but interesting descriptive study entitled “Bioresorbable vascular scaffolds in saphenous vein graft disease. Pilot results from the OCTOPUS registry” [5]. It is just a descriptive series of 6 patients undergoing percutaneous coronary intervention (PCI) with implantation of the Absorb BRS (Abbott Vascular, Santa Clara, CA) in saphenous vein grafts, but very relevant to expand the indication of the BRS to this challenging (still off-label) scenario. To date there have been several case reports of BRS implanted in saphenous vein grafts [6, 7], some of them reported by the same authors of the...


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