Acute Coronary Syndromes: Direct Stent for All?

The development of pre-mounted stents, as well as numerous technical enhancements, have contributed to the improvement of stent profile, flexibility and safety. Stent placement without predilation has become feasible and can virtually be carried out by all interventional cardiologists. Indeed, after a number of successful preliminary experiences, the operators have been able to modify their implantation techniques and to start performing direct stenting routinely in selected patients.1–5 In this setting, the questions remain: What patients are eligible for direct stenting? Are there still contraindications? What benefits can be expected from a direct stenting strategy? Several randomized studies comparing direct stenting with stent implantation after balloon predilatation have confirmed the feasibility of direct stenting in selected patients with stable coronary syndromes.6,7 In a patient population from which elderly patients and complex or very calcified lesions are excluded, the success rate of direct stenting is over 90%. Indeed, when high-risk lesions are avoided (calcified, long lesions or tortuous segments), failed attempts at direct stenting are infrequent and can be successfully addressed by performing predilatation after withdrawal of the pre-mounted stent. In rare instances, stent deployment may require patience and perseverance, and sometimes the use of rescue intrastent atherectomy with rotablator, before success can be achieved (personal experience). This strategy is cost-effective and allows a reduction in patient exposure to radiation and to contrast media as previously underlined in prospective series. The controversial question as to whether direct stenting may be associated with a reduction in the restenosis rate has been raised.8 However, despite a possible reduction in arterial wall damage (aggression), an actual reduction in the occurrence of restenosis has not been demonstrated in any series.6 In this issue of the Journal, Atmaca et al. demonstrate the feasibility and the potential benefit of direct stenting See Atmaca et al. on pages 308–312 applied to unstable lesions in the setting of acute coronary syndrome. Of 840 patients who underwent percutaneous coronary intervention for acute coronary syndrome, a total of 145 patients with single-vessel disease were divided into 2 treatment strategy groups, a direct stenting group including 71 patients and a stenting after predilatation group including 74 patients. It is important to note that a high percentage of the patients included in the study suffered ST- and non-ST segment elevation — of which 27 and 55 patients respectively — accounting for 57% of the study population. The rates of primary success were equivalent in the two study groups and direct stent implantation failed in only 5.4% of patients (2 stents were lost). As already underlined in previous reports, the strategy applied allowed shorter procedure time, reduced fluoroscopic exposure (10.1 ± 3 min vs. 16.2 ± 5 minutes; p = 0.001) and lower use of contrast media (125 ml ± 60ml vs. 155 ml ± 71 ml; p = 0.006). As stated by the authors, direct stent implantation in selected patients with ACS is safe and equivalent to conventional stenting with respect to the occurrence of major cardiac events. However, it is interesting to note that both angiographic and clinical data suggest that direct stent implantation may be superior to conventional stent implantation: the mean number of inflations was significantly lower with direct stenting (1.3 ± 0.6 vs. 3.2 ± 0.6; p

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