ABSTRACT
Stent insertion without pre-dilatation carries the appeal of quicker cases that cost less in terms of finance and radiation exposure. There is the theoretical possibility that there is less trauma to the vessel wall and the suspicion that, particularly in vein graft disease, there will be less distal embolization. Such appealing concepts have led to great interest in this technique. Randomized and controlled trials are currently underway but the current body of evidence is based upon observational data. Certain clinical features and types of lesion are thought to be favourable for direct stenting, including:
• Recent history of angina and especially acute coronary syndromes
• Vein grafts • Lack of calcification
Most interventionists by now have had the sinking feeling when the stent will not access or cross the lesion and becomes loose on its delivery system, and at these times, if we are honest, we ask ‘why am I trying to do this?’ The response to such a crisis is an important component to the skill of the direct stent enthusiast because clearly it can make the difference as to whether the stent is lost or not. There are certainly a variety of disadvantages to direct stenting:
• Difficulty with visualization and positioning once the stent delivery system encroaches into the lesion
• Failure to pre-dilate can lead to deployment of a stent that is suboptimal in diameter or length
• Stent expansion is sometimes incomplete at the heart of a tough lesion, thus necessitating the use of a non-compliant balloon (negating the cost advantage)
It seems likely that direct stenting has a niche in the armamentarium of the interventionist and forthcoming trials may help to pinpoint the nature of that niche. As can be seen from the response of our experts to these illustrative cases, there is not yet consensus!
