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REVIEW ARTICLE

Provisional stenting strategies: systematic overview and implications for clinical decision-making

Warren J. Cantor, MD^*, Eric D. Peterson, MD, MPH, FACC^*, Jeffrey J. Popma, MD, FACC, James P. Zidar, MD, FACC^*, Michael H. Sketch, Jr., MD, FACC^*, James E. Tcheng, MD, FACC^* and E. Magnus Ohman, MD, FACC^*

^* Duke Clinical Research Institute, Durham, North Carolina, USA
Brigham and Women’s Hospital, Boston, Massachusetts, USA

Manuscript received August 9, 1999; revised manuscript received March 23, 2000, accepted May 24, 2000.

Reprint requests and correspondence: Dr. Warren J. Cantor, Division of Cardiology, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario, Canada MSB 1WB
canto001{at}mc.duke.edu

Coronary stents reduce the rates of abrupt closure, emergency coronary artery bypass graft surgery and restenosis, but do not prevent myocardial infarction or death at six months. The financial burden of increased stent use and the difficulty in managing in-stent restenosis have provided the impetus to develop provisional stenting strategies. Patients at low risk for restenosis after balloon angioplasty may not derive additional benefit from stent implantation and may be successfully managed with percutaneous transluminal coronary angioplasty (PTCA) alone. Numerous patient, lesion and procedural predictors of restenosis have been identified. Postprocedural assessment using quantitative coronary angiography, intravascular ultrasound (IVUS), coronary flow velocity reserve (CVR) or fractional flow reserve (FFR) may further enhance the ability to predict adverse outcomes after PTCA. Several studies have been performed to investigate the feasibility of provisional stenting strategies using various modalities to identify low risk patients who could be managed with PTCA alone. An optimal or "stent-like" angiographic result after PTCA is associated with favorable clinical outcomes. Preliminary results of studies using IVUS or CVR to guide provisional stenting appear promising. Angiography alone may be inadequate to identify truly low risk patients and may need to be combined with clinical factors, assessment of recoil, IVUS or physiologic indexes. Strategies that avoid unnecessary stenting in even a small proportion of patients may have large impacts on health care costs. Provisional stenting may potentially reduce costs and rates of in-stent restenosis without compromising the quality of health care delivery.

Abbreviations and Acronyms   CVR = coronary flow velocity reserve   FFR = fractional flow reserve   IVUS = intravascular ultrasound   LAD = left anterior descending coronary artery   MI = myocardial infarction   MLD = minimum lumen diameter   PTCA = percutaneous transluminal coronary angioplasty   QCA = quantitative coronary angiography   TLR = target lesion revascularization

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