A roadmap for managing coronary stent underexpansion
State-of-the-art review
A state-of-the-art review, published today in the Journal of the American College of Cardiology (JACC), presents critical advancements in the diagnosis and treatment of coronary stent underexpansion, a complication of an interventional cardiac procedure used to improve blood flow through blocked arteries.
Lead author of the review is Dr. Primero Ng, acting instructor and fellow in complex coronary therapies and senior author is Dr. Lorenzo Azzalini, associate professor and director of Interventional Cardiology Research.
Complications and risks
Heart diseases that lead to blocked coronary arteries are often treated with percutaneous coronary intervention (PCI), a medical procedure during which a stent is placed in the artery to help it stay open.
While the condition is widely recognized, there is currently no standardized treatment approach.
Stent underexpansion, a complication of PCI, occurs when the stent is unable to fully expand due to hard plaque buildup or poor placement and results in increased risk for serious problems like heart attacks or the need for additional treatments.
Latest evidence and strategies
The review in JACC brings together insights from leading experts in interventional cardiology, offering a much-needed roadmap for tackling this complex clinical challenge.
“Our review consolidates the latest evidence and treatment strategies to help interventional cardiologists manage stent underexpansion more effectively,” said Dr. Primero Ng, lead author of the review.
“Furthermore, in line with recent data, we emphasize the crucial role of intravascular imaging, such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), in accurately diagnosing the condition and guiding treatment decisions.”
The review explores a range of advanced therapeutic strategies that are currently in use to overcome stent underexpansion. Some of these techniques include:
- Super-high-pressure balloons: These balloons apply intense pressure to expand the stent when it is resistant to opening.
- Intravascular lithotripsy: A technology that uses sonic pressure waves to break up hardened calcium in the artery, making it easier to expand the stent.
- Excimer laser coronary atherectomy: A laser-based tool that helps clear out calcified plaques to allow the stent to expand fully.
- Rotational and orbital atherectomy: Special devices that "drill" through the artery to remove blockages, offering an alternative solution for severe cases where other strategies have failed.
The review also discusses additional therapies that seek to reduce the chance of new blockages forming after the procedure.
Roadmap for better care
“Our goal is to provide a practical, evidence-based framework that any interventional cardiologist can apply in real-world settings,” said Dr. Lorenzo Azzalini, senior author of the review.
Through a comprehensive assessment of current PCI care techniques and collaboration with experts, the review notably includes a proposed treatment algorithm, designed to guide clinicians in selecting the most effective therapy based on imaging data and lesion characteristics.
The authors found that this individualized approach not only enhances procedural success but also reduces long-term complications and improves overall patient outcomes.
“While we have made strides in treating stent underexpansion, there is still much work to be done,” Azzalini said.
“We urgently need large-scale clinical trials to help validate our approach and establish definitive guidelines that will help improve the outcomes of PCI.”
Azzalini stresses the importance of disseminating best practices within the interventional cardiology community for preventing PCI complications as well as optimal techniques for treating stent underexpansion when it occurs.
Long-term advances
As one of the most comprehensive reviews on stent underexpansion published to date, this study serves as a crucial reference for interventional cardiologists, researchers, and healthcare professionals seeking to refine PCI techniques. With its clear clinical roadmap, it aims to shift the paradigm toward more precise, individualized treatments, ultimately ensuring better long-term outcomes for patients worldwide.