Provisional versus routine stenting: routine stenting is here to stay.

Abstract

The introduction of coronary artery stents into widespread clinical use in the mid-1990s was a significant advance that almost rivals the introduction of balloon angioplasty itself 15 years earlier. It is noteworthy that the success of stents required several paradigm shifts. For example, higher-pressure balloon inflations and slight oversizing were needed to achieve full stent expansion (anathema in balloon angioplasty), and antiplatelet therapies were required rather than anticoagulation, including a reduction and now almost elimination of heparin. Yet, these changes were quickly accomplished. Technical advances in equipment also occurred, and now stenting, quite literally, has become the standard in clinical practice when it can be performed (which is most of the time). One curious and intriguing question that arises with any new device, and stents are no exception, is whether they are needed in all situations where they are being used. Is it possible that balloon angioplasty alone might be sufficient for excellent immediate and long-term benefit, provided the final procedural result is good enough? If one could determine this to be true, then such a strategy would avoid the additional cost of a stent and the problem (or pseudo-problem) of in-stent restenosis. However, a provisional stent strategy raises the further and not inconsiderable question of how to decide when balloon angioplasty results are “good enough.” The limitations of standard angiography notwithstanding, is there anything better than the eyes and minds of experienced angiographers? Additional “objective” measures to assess procedural results have long been sought. A number of investigators have championed intracoronary ultrasound as one approach, whereas others suggest alternative methods. In this issue of Circulation , 2 separate groups report their findings using combined anatomic and functional coronary measures to assess balloon angioplasty results for the purpose of provisional stenting.1 2 These measures are on-line quantitative coronary arteriography …