Standing on Solid Ground?

Abstract

In this issue of Circulation: Cardiovascular Interventions , Im et al1 are assessing the fate and clinical significance of optical coherence tomography (OCT)–detected incomplete stent apposition (ISA) in drug-eluting stents (DESs). This work is addressing an important clinical question because interventional cardiologists are obsessed with achieving optimal stent expansion since the early days of coronary stent implantation, and this is still today considered the best way to prevent acute and long-term sequelae such as stent thrombosis. Indeed, intravascular ultrasound (IVUS) studies unveiled the prominent role of stent underexpansion in the pathogenesis of stent thrombosis in the past.2 Therefore, optimal stent expansion allowing to achieve a high acute lumen gain is of concern ever since. This knowledge triggered the development of improved stent design and high-pressure balloons, as well as the use of invasive imaging technologies, such as IVUS, to diagnose stent underexpansion. Back then, complete apposition of the stent struts against the vessel wall3 was an implicit prerequisite for optimal stent expansion. ISA, defined as the absence of contact of ≥1 stent strut with the vessel wall, became an entity in its own right in the late 1990s with the introduction of intracoronary brachytherapy and the IVUS observation of late-acquired ISA.4 This interest extended later, in the beginning of the millennium, to the first-generation DES.5, …