ACC expert consensus document on coronary artery stents

Stenting, particularly with high pressure postdeployment balloon inflation and adjunctive therapy with acetyl salicylic acid (ASA) and ticlopidine have been proven to reduce angiographic and clinical restenosis compared to conventional dilatation. In several areas, widespread clinical practice patterns have occurred in advance of rigid controlled scientific data. The consensus recommendations are based upon scientifically controlled trials, single and multicenter experience and clinical practice. In selected patients with focal stenosis in native coronary arteries, stent implantation with high pressure postdeployment inflation and adjunctive therapy with ASA and ticlopidine have been definitively proven to reduce angiographic and clinical restenosis compared to conventional dilatation. Stenting can improve the longer-term outcome of selected patients being treated for chronic total occlusion and can result in improved restenosis rates in selected patients. Vein graft disease remains a significant problem because of the often diffuse nature of the process and the underlying severe coronary artery disease. In selected patients and lesions, stents have resulted in improved initial success rates and larger acute angiographic gain. Restenosis rates and longer-term morbidity remain increased. Stenting is a promising approach to optimize the results of catheter-based therapy and to treat complications of primary angioplasty. Whether stenting should be used only to treat suboptimal results or should be recommended as a primary therapy is still under study. Randomized trials within the next 2 years should resolve these issues. Stenting results in improved outcome in selected patients with restenosis following conventional percutaneous transluminal coronary angioplasty (PTCA). In contrast, the role of stenting for instent restenosis is uncertain. It may be useful for focal stenoses, and when conventional dilatation does not result in an excellent angiographic outcome. For diffuse instent restenosis, there are insufficient data upon which to base a recommendation. The currently available data on treatment of small vessels indicate that it is safe but that it does not result in improved longer-term outcome compared with conventional PTCA provided that dilatation gave a satisfactory initial result. Stents remain useful in this setting if the results of conventional PTCA are suboptimal with persistent significant residual obstruction. The treatment of long lesions or diffuse disease remains problematic. Long stents or multiple stents may play an important role when the result of conventional dilatation is suboptimal. Restenosis rates appear to be increased but may be improved compared with conventional PTCA. Intravascular ultrasound provides substantial information as an adjunctive approach to guide stent placement. Accumulating data indicate that it can be used to optimize early and longer-term outcome in selected patients.