Management of Coronary Stent Underexpansion (JACC February 2025-1)-Article: Management of Coronary Stent Underexpansion

Article: Management of Coronary Stent Underexpansion

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The JACC state-of-the-art review article addresses the issue of coronary stent underexpansion, a significant limitation in percutaneous coronary intervention (PCI) that detrimentally affects patient outcomes. Stent underexpansion occurs when a stent does not sufficiently expand compared to the adjacent reference segment, leading to increased risks of in-stent restenosis (ISR), stent thrombosis, and myocardial infarction. These complications are often attributed to factors such as severe calcification, inadequate lesion preparation, and suboptimal stent deployment.<br /><br />Current interventions for managing underexpansion include a range of techniques, although no consensus exists on the optimal treatment approach due to a lack of large-scale, prospective studies. Intravascular imaging (IVI), such as intravascular ultrasound and optical coherence tomography, is highlighted as a critical tool for diagnosing and managing stent underexpansion by detailing vessel and stent evaluation, understanding stent failure mechanisms, and guiding treatment strategies.<br /><br />Various strategies are employed to address stent underexpansion, like high-pressure balloon dilatation, excimer laser coronary atherectomy (ELCA), rotational and orbital atherectomy, and intravascular lithotripsy (IVL). Each method has unique advantages and limitations, and a tailored approach based on the individual case is suggested for optimal outcomes.<br /><br />There is a call for standardized definitions and treatment protocols for stent underexpansion to improve patient care and outcomes, given its significant impact on reintervention rates and mortality. The review proposes algorithmic recommendations based on existing evidence and clinical experience, emphasizing the importance of achieving optimal stent expansion during the initial stenting procedure to prevent complications and improve clinical results. The review also considers therapeutic options like drug-coated balloons and intravascular brachytherapy for dealing with ISR, especially with complicated cases involving multiple stent layers.

Keywords

coronary stent underexpansion

percutaneous coronary intervention

in-stent restenosis

stent thrombosis

intravascular imaging

high-pressure balloon dilatation

atherectomy

intravascular lithotripsy

standardized treatment protocols

drug-coated balloons