Percutaneous coronary artery intervention: The last five years and the next five years

Abstract

In this issue of the Journal, Peterson et al I analyze the evolution of device use and outcomes of percutaneous coronary intervention (PCI) from 1994 through 1997 using registry data from 12 US hospitals participating in the National Cardiovascular Network database. Two tmdeniable trends are apparent. First, atheroablative devices, which were initially greeted with enthusiasm, have become niche tools, at least for now. The 2 most widely used of these, directional and rotational atherectomy, have declined from a combined usage rate of approximately 25% of all PCI procedures in 1994 to less than 10% in 1997. Second, during the same period there has been a dramatic increase in the use of stents from 5% to 69%, with an associated increased rate of procedural success and a decreased need for in-hospital repeat revascularization. These findings are provocative and raise many impor tant questions: (1) Are these trends in device use and outcome confirmed by other data sets? (2) Why has stent use increased so dramatically, and what impact has this had on the overall use of both PCI and surgical coronary revascularization? (3) Why have atheroablative techniques been reduced to niche status? (4) What are the limitations of coronary stenting, and can they be overcome? (5) What changes will occur over the next 5 years? The increased use of stents is confirmed by a wide variety of mult icenter surveys, registry data, and singlecenter experiences. For example, in a 1-week survey in May 1997 conducted at the 17 centers participating in the BARI (Bypass Angioplasty Revascularization Investigation) trial, 57% of the 370 patients undergoing PCI received stents. 2 In New York state, where all PCI procedures are reported in an audited registry, the percentage of patients receiving intracoronary stents has increased from 5% in 1994 to 81% in 1998, with an associated decrease in the need for bypass surgery within 24 hours of PCI from 1.7% in 1994 to 0.4% in 1998. At New York University, where more current data are available, stent use has increased from 4% of procedures in 1994 to 88% of procedures in the first 6 months of 1999.