Techniques

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Direct Stenting

A review of direct stenting with percutaneous coronary intervention.

Direct stenting, or stenting without lesion pre-dilatation,  is employed in 30-40% of PCIs and has been compared to stenting with pre-dilatation in numerous observational studies as well as randomized trials. It has been shown to be effective in elective as well as non-elective patients undergoing PCI due to unstable angina with or without ST-segment elevation myocardial infarction (STEMI)1-4. In select lesions (typically those with lower degrees of lesion calcification and vessel angulation), high rates of technical and procedural success are observed5.

The clinical benefits of direct stenting have been well documented for some time. Prospective studies as well as meta-analyses demonstrate 22% – 50% reductions in restenosis, TLR, MI and death associated with direct stenting compared to conventional stenting2,6-8.

Multiple studies consistently demonstrate the superior clinical outcomes associated with direct stenting, which may be driven by:

  • Reduced wall damage and inflammatory response from vessel preparation (balloon pre-dilatation)9
  • Greater preservation of residual endothelium9
  • Better longitudinal centering of the stent on the lesion with more uniform axial redistribution of plaque10
  • Reduced microcirculatory dysfunction and/or distal embolization11

Pre-dilatation may induce intimal dissection necessitating multiple or altogether longer stents, increasing the risk of restenosis12.  Concern also exists in definitively covering the vasculature disturbed during pre-dilatation.

With direct stenting, some operators remain uncomfortable with the risk failing to initially cross the lesion, inability to accurately determine appropriate stent size and possibility of stent embolization. However in addition to appropriate lesion selection, technologies dedicated to safely and consistently performing direct stenting can minimize these risks.

Working with radiation is like keeping a pet tiger in your living room.

—John Sutherland, MD, cardiologist and former radiation safety officer at the Arizona Heart Institute.

Direct stenting offers significant reductions in procedure time, radiation exposure, contrast administration, adjunctive material use and ultimately cost have been realized with direct stenting13-14. The effects of radiation exposure in particular is becoming an alarming concern. Cases of cataracts, carotid artery disease and brain tumors reported by interventionalists and supposedly linked to routine exposure to radiation, have recently emerged. Anything that can be done to limit exposure to radiation, including reducing procedure steps and time through direct stenting, can have a beneficial impact.

Direct stenting is routinely combined with TRI and reduces the steps involved with a conventional approach to PCI, streamlining procedures, reducing contrast use (and the risk of contrast-induced nephropathy for renal-impaired patients) and shortening procedure times.

With improved, lower-profile technologies dedicated to the safe and reliable direct stenting of appropriate lesions, all parties involved in coronary stenting – patients, physicians, providers and payers – will benefit from streamlined procedures, superior long-term clinical outcomes and resource savings.

Resources:

  1. Carrie D et al. Comparison of direct coronary stenting with and without balloon predilatation in patients with stable angina pectoris.  BET (Benefit Evaluation of Direct Coronary Stenting) Study Group. Am J Cardiol. 2001;87:693-8.
  2. Ly H et al. Angiographic and clinical outcomes associated with direct versus conventional stenting among patients treated with fibrinolytic therapy for ST-elevation acute myocardial infarction. Am J Cardiol. 2005;95(3):383-6.
  3. Cuellas C et al. Direct stent implantation in acute myocardial infarction. The DISCO 3 study. Rev Esp Cardiol. 2006;59:217-24.
  4. Dziewierz A et al. Impact of direct stenting on outcome of patients with ST-elevation myocardial infarction transferred for primary percutaneous coronary intervention (from the EUROTRANSFER registry). Cath and Cardiovasc Interv. 2014;84:925-931.
  5. Stys T et al. Direct coronary stenting without balloon or device pretreatment: acute success and long-term results. Cath and Cardiovasc Interv. 2001;54:158-163.
  6. Burzotta F et al. Comparison of outcomes (early and six-month) of direct stenting with conventional stenting (a meta-analysis of ten randomized trials). Am J Cardiol. 2003;91:790-6.
  7. Ormiston J et al. Direct stenting with the TAXUS Liberte drug-eluting stent. J Am Coll Cardiol Intv. 2008;1(2):150-160.
  8. Piscione F et al. Is direct stenting superior to stenting with predilation in patients treated with percutaneous coronary intervention? Results from a meta-analysis of 24 randomized controlled trials. Heart. 2010;96(8):588-594.
  9. Rogers C et al. Endogenous cell seeding. Remnant endothelium after stenting enhances vascular repair. Circulation. 1996;94:2909-2914.
  10. Brueck M et al. Direct coronary stenting versus predilatation followed by stent placement. Am J Cardiol. 2002;90:1187-1192.
  11. Cuisset T et al. Direct stenting for stable angina pectoris is associated with reduced periprocedural microcirculatory injury compared with stenting after pre-dilation. J Am Coll Cardiol. 2008;51:1060-5.
  12. Foley D et al. The influence of stent length on clinical and angiographic outcome in patients undergoing elective stenting for native coronary artery lesions; final results of the Magic 5L study. Eur Heart J. 2001;22:1585-93.
  13. Ijsselmuiden A et al. Direct coronary stenting compared with stenting after predilatation is feasible, safe, and more cost-effective in selected patients: evidence to date indicating similar late outcomes. Int J Cardiovasc Intervent. 2003;5:143-50.
  14. Caluk J et al. Direct coronary stenting in reducing radiation and radiocontrast consumption. Radiol Oncol. 2010;44(3):153-7.