ABSTRACT
Provisional stenting Recent trials comparing primary stenting with stent-like PTCA results suggest that stenting is
not always indicated in all PCIs.6-8 The concept of provisional stenting evolved as efforts to optimize outcomes and control the costs of PCIs have intensified. A recently published survey of European interventional cardiologists reported that 2% unconditionally stent focal de novo lesions in native coronary arteries and 44% refrain from stenting after optimal ‘stent-like’ results ( 30% residual stenosis).9 The ability to identify patients at risk for restenosis, thus warranting stent placement, remains suboptimal. Several strategies were developed to identify lesion characteristics predictive of restenosis after PTCA. Rodriguez et al identified early lumen loss after PTCA as an important predictor of angiographic restenosis at 6 months.10 As a result, the Optimal Coronary Balloon Angioplasty (OCBAS) investigators randomized 116 patients who underwent PTCA and had optimal angiographic results ( 30% diameter stenosis and no indication for bailout stenting) to primary stenting (57 patients) or no further therapy.11 Eight patients (14%) in the PTCA alone group crossed over to the stent group owing to early lumen loss ( 0.3 mm or 10% increase in diameter stenosis) at angiography 30 minutes after the initial PTCA. Using this strategy, angiographic restenosis occurred in 19.2% of the stent group and 16.1% (p ns) of the PTCA group when analysed as intention to treat. TVR was 17.5% and 13.5%, respectively (p ns). Cost
analysis revealed added expense to the stent strategy owing primarily to the cost of stents (estimated at $3000/stent at that time) in accordance with the cost analysis results of BENESTENT which were done in the setting of full anticoagulation. Of note, 206 patients were screened for the study, and 86 (42%) were not randomized owing to suboptimal results or complications of PTCA. Other investigators have utilized physiologic assessment of the coronary flow either with coronary flow reserve (CFR)12 or fractional flow reserve (FFR)13 after PTCA to predict restenosis. The utility of this approach in various subgroups guiding the utilization of stents remains untested.
