Stent Optimization Using Adjunctive Balloon Dilatation in the Era of Second-Generation Drug-Eluting Stents

Percutaneous coronary intervention (PCI) using both balloon angioplasty and coronary stents has markedly reduced adverse cardiac events in patients with ischemic heart disease. Drug-eluting stents (DES) could further decrease the incidence of target vessel revascularization (TVR) to 5%–10% compared to bare-metal stents (BMS) or balloon angioplasty alone.1) Despite its clinical benefits, stent failure including stent thrombosis or in-stent restenosis (ISR), is the major concern after coronary stenting; it is associated with worse clinical outcomes in patients who received PCI using coronary stents. Among mechanisms of ISR and stent thrombosis, stent under-expansion and stent mal-apposition are important mechanical factors which can cause stent failure.1)2) For BMS, it is accepted that good apposition and full stent expansion are associated with reduced risk of ISR and stent thrombosis.3) However, few studies have investigated whether adjunctive balloon dilatation after DES implantation could reduce the incidence of stent-related complication or failure. Brodie suggested that adjunctive balloon post-dilatation following deployment of first-generation DES should be used in the majority of patients to reduce stent thrombosis and TVR.4) Romagnoli et al.5) determined through an analysis of the literature that achieving adequate stent expansion (both BMS and DES) during PCI is important to reduce restenosis, the need for TVR and stent thrombosis. Although suboptimal stent expansion frequently occurs after DES deployment in 24%–28% of all cases, routine post-dilatation is not cost-effective, thus imaging devices such as intravascular ultrasound (IVUS) are recommended.6) There is also lack of data regarding post-dilatation after second-generation DES implantation.