To stent or not to stent

Coronary artery stenting has definitely been proven to improve results of p ercutaneous revascularisation in a large number of patients. Stenting reduc es restenosis in large vessels above 3 mm diameter. Stenting has not solved the problem of restenosis but in spite of the inevitable in-stent restenos is due to neointimal proliferation seems to yield better long-term results than conventional PTCA. Adjunctive pharmacological treatment with aspirin a nd clopidogrel in combination with improved stent deployment techniques has reduced the incidence of subacute stent thrombosis, GP IIb/IIIa inhibition is a promising mean for the reduction of procedure related ischaemic event s and complications not only with stent implantation but also with conventi onal PTCA. Other new devices may further influence the treatment choices of stenting versus conventional PTCA in the future. Novel approaches such as brachytherapy and molecular genetic approaches to reduce in-stent restenosi s are currently being investigated but to dare no conclusions can be drawn as to their future place in clinical practice, From a mechanistic standpoin t it seems obvious to give all our efforts to protect patients with coronar y atherosclerosis from loss of myocardium either with coronary artery bypas s grafting or percutaneous revascularisation. As both approaches are pallia tive in nature, it may be useful to attempt percutaneous revascularisation in patients amenable to this therapy and thus obviate or delay the need for definitive revascularisation by coronary artery bypass grafting. At the en d of this discussion we would like to remind that medical therapy for coron ary artery disease is of utmost importance as all revascularisation procedu res do not influence the underlying disease. Besides symptomatic relief of angina, treatment of heart failure, and other beneficial strategies to impr ove endothelial function, medical therapy with lipid lowering compounds tog ether with risk factor control offers the possibility to delay progression of coronary artery disease.