ACC EXPERT CONSENSUS DOCUMENT ON CORONARY-ARTERY STENTS

Stenting, particularly with high pressure postdeployment balloon infla tion and adjunctive therapy with acetyl salicylic acid (ASA) and ticlo pidine have been proven to reduce angiographic and clinical restenosis compared to conventional dilatation. In several areas, widespread cli nical practice patterns have occurred in advance of rigid controlled s cientific data. The consensus recommendations are based upon scientifi cally controlled trials, single and multicenter experience and clinica l practice. In selected patients with focal stenosis in native coronar y arteries, stent implantation with high pressure postdeployment infla tion and adjunctive therapy with ASA and ticlopidine have been definit ively proven to reduce angiographic and clinical restenosis compared t o conventional dilatation. Stenting can improve the longer-term outcom e of selected patients being treated for chronic total occlusion and c an result in improved restenosis rates in selected patients. Vein graf t disease remains a significant problem because of the often diffuse n ature of the process and the underlying severe coronary artery disease . In selected patients and lesions, stents have resulted in improved i nitial success rates and larger acute angiographic gain. Restenosis ra tes and longer-term morbidity remain increased. Stenting is a promisin g approach to optimize the results of catheter-based therapy and to tr eat complications of primary angioplasty. Whether stenting should be u sed only to treat suboptimal results or should be recommended as a pri mary therapy is still under study. Randomized trials within the next 2 years should resolve these issues. Stenting results in improved outco me in selected patients with restenosis following conventional percuta neous 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 curren tly available data on treatment of small vessels indicate that it is s afe but that it does not result in improved longer-term outcome compar ed with conventional PTCA provided that dilatation gave a satisfactory initial result. Stents remain useful in this setting if the results o f conventional PTCA are suboptimal with persistent significant residua l obstruction. The treatment of long lesions or diffuse disease remain s problematic. Long stents or multiple stents may play an important ro le when the result of conventional dilatation is suboptimal. Restenosi s rates appear to be increased but may be improved compared with conve ntional PTCA. Intravascular ultrasound provides substantial informatio n as an adjunctive approach to guide stent placement. Accumulating dat a indicate that it can be used to optimize early and longer-term outco me in selected patients.