Provisional versus routine coronary stenting. A review

Coronary stenting is the most commonly used coronary revascularization procedure due to the ease of use, safety and evidence that it has predictably better results in several coronary lesion subsets than balloon angioplasty alone. As opposed to routinely stenting all the stentable coronary lesions, in the provisional stenting approach, all the lesions would first be optimally angioplastied and a stent used only in the patients who would not have as good an outcome with balloon angioplasty alone. There are several theoretical advantages to this approach. The two different approaches are compared in this review. Retrospective studies and studies using immediate vessel recoil after optimal balloon angioplasty seemed to suggest that stent-like results after balloon angioplasty had similar target revascularization rates as stenting. However, a prospective randomized study primarily using angiography to guide provisional stenting suggests better outcome in the routine stenting strategy. If provisional stenting were to have similar long-term results as routine stenting, it has to be guided by techniques other than coronary angiography like coronary flow reserve or intravascular ultrasound. Even then, over half of the balloon angioplasty group will need stenting. Besides, based on prospective randomized studies, this strategy is not economically more attractive than the routine stenting strategy. Therefore routine stenting strategy is justifiable for most operators who use coronary angiography to guide their interventions. With further advancement in the stent technology like drug coating routine stenting may be even further attractive.