A Call for Provisional Stenting

Abstract

During the past 20 years, the equipment used to perform percutaneous coronary revascularization has undergone a dramatic transformation from simple balloon dilatation catheters to sophisticated mechanical devices and endoprostheses. The impetus for this evolution in technology was initially a byproduct of suboptimal immediate and long-term results obtained with standard balloon angioplasty. New techniques, including directional and rotational atherectomy, have resulted in improved procedural success rates, especially for more complex lesion subtypes, although their ability to curtail restenosis remains controversial.1,2 Intracoronary stents have had a dramatic impact on reduction of the incidence of acute complications after failed balloon angioplasty and represent the only currently available strategy shown to limit both clinical and angiographic restenosis. 3-12Based on these advantages, stent implantation is used in approximately half of all percutaneous interventions in the United States. However, despite their proven benefits, coronary stents continue to be accompanied by several theoretical and practical limitations: they are costly, typically associated with a more marked degree of neointimal formation than balloon angioplasty, and difficult to use with some lesion subsets such as bifurcation stenoses, and they have engendered the new and difficult-to-treat entity of in-stent restenosis.Although the major focus in the field of interventional cardiology over the past decade has been on the development of new devices and adjunctive pharmacological therapies, the short-and long-term success rates after standard balloon angioplasty have improved significantly. Part of the improvement is likely a manifestation of enhanced operator experience and better equipment, but the results of balloon angioplasty have also benefited greatly from the availability of coronary stents for both "bailout" (for actual or threatened abrupt closure) or "backup" (for suboptimal balloon results) indications, potentially allowing a strategy of more aggressive balloon dilatation than could be safely performed in the pre-stent era. This report details the forces that resulted in the shift from reliance on balloon angioplasty as the primary mode of therapy for the majority of percutaneous interventions and, with the use of data from several recent clinical trials, will provide the rationale for a potential return to the use of balloon angioplasty (with provisional stent placement) as the predominant means of coronary revascularization.

Gene transfer using the mature form of VEGF-D reduces neointimal thickening through nitric oxide-dependent mechanism

“…1 Although drugeluting stents have alleviated this problem, there is a clear need to develop other treatment strategies. Local gene transfer to vascular wall could offer an alternative approach for the prevention of restenosis after PT(C)A and coronary stenting.…”

Frontiers in Interventional Cardiology

“…Whether indeed stenting should be avoided when possible or actually applied more frequently is an unsettled issue. 35 Notwithstanding the provisional stent debate, the interaction of stenting and antiplatelet therapy is clearly a critical one for future optimization of patient outcomes.…”

Limitations of coronary angiography compared with intravascular ultrasound: Implications for coronary interventions☆

“…To address these issues, the strategy of ''provisional stenting'' has been developed. 277 In this method, an attempt is made to use balloon dilatation alone. IVUS guidance is used to choose the balloon size to obtain the best possible angioplasty result in terms of lumen crosssectional area.…”