Residual coronary dissections after drug-eluting stenting: the good, the bad, and the uglyThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

Abstract

This editorial refers to ‘Incidence, predictors, and outcomes of coronary dissections left untreated after drug-eluting stent implantation’† by G.G.L. Biondi-Zoccai et al ., on page 540 The article of Biondi-Zoccai et al. 1 provides a unique opportunity to review the management of coronary dissections induced during percutaneous coronary interventions. For more than 25 years, interventional cardiologists have been facing this challenging situation using different approaches.2–5 Initially, prolonged balloon inflation was the only available therapy. If unsuccessful, patients with acute or threatened vessel closure had only urgent coronary artery bypass surgery as a therapeutic alternative to prevent or limit myocardial damage. The introduction of coronary stents, with their inherent scaffolding properties, dramatically changed this scenario and allowed the dissection flap to be readily tackled. However, whether or not routine stenting is systematically required to seal even minor residual coronary dissections has been a matter of continuous debate for the last decade.2–5 Currently, the soliloquy ‘ To stent or not to stent : that is the question ’4 is being revisited in the new era of drug-eluting stents. Only inquiring into the facts (the good, the bad, and the ugly) may guide us in solving this dilemma. However, what do we know about the pathophysiology, predisposing factors, prognostic implications, and management of residual coronary dissections? Coronary dissections represent the ‘natural’ response of the coronary wall to the mechanical injury of vessel stretching caused by high-pressure balloon inflation. In fact, the mechanism of lumen enlargement after balloon angioplasty relies upon the occurrence of a ‘controlled’ coronary dissection. If this ‘therapeutic’ dissection is relatively confined, both in depth and in length, the lumen gain obtained guarantees a high coronary flow that largely offsets the associated drawbacks of high/low shear stress zones caused by winding dissection planes and the … *Corresponding author. Tel: +34 91 3303289; fax: +34 91 3303289. E-mail address : falf{at}hotmail.com