Angiography-guided routine coronary stent implantation results in suboptimal dilatation

The resistance of the atherosclerotic lesion counteracts the expansion of the stent, resulting in suboptimal stent expansion. Intravascular ultrasound provides more precise information on stent expansion than coronary angiography but adds cost and time to the percutaneous transluminal coronary angiography procedure. The aim of this study was to evaluate the need for intravascular ultrasound at routine angiography-guided high pressure stent implantation by comparing stent expansion with predefined intracoronary ultrasound criteria for optimal stent implantation. In 32 patients, 48 stents (35 NIR, 12 AVE, and 1 Cordis) were implanted in A, B, and C stenoses using a high-pressure inflation technique until an optimal result was achieved according to angiography. Stent expansion was then evaluated by intravascular ultrasound as minimal lumen diameter, minimal lumen area, proximal and distal stent area, and a minimal lumen area symmetry index. These variables were then compared with the nominal stent size in vitro. Finally the stents were also evaluated with respect to the MUSIC criteria, ie, strict criteria regarding symmetry, apposition, and vessel geometry according to intravascular ultrasound after stent expansion. Forty-five stents could be completely analyzed. The mean balloon inflation pressure was 12.8 (range, 10-17) atm. The nominal stent size was not achieved in any patient. Minimal lumen diameter attained 77% and minimal lumen area 78% of expected nominal values (p<0.0001), distal stent area 88% (p < 0.001), and proximal stent area 92% (ns). Application of the MUSIC criteria showed that almost all stents (96%) had good stent apposition and symmetry index. Optimal proximal stent entrance was found in 70%. Optimal minimal lumen area in comparison to the reference areas was present in 41%. This lead to fulfilling of all MUSIC criteria in 47% of the stents. If nominal stent size had been achieved, symmetry index and apposition would have been fulfilled in all cases and optimal minimal lumen area increased to 75%. Acceptable proximal entrance however would have decreased to 55% and the fulfillment of all MUSIC criteria would increase only to 52%. In routine angiography-guided stent implantation in stenoses with a wide range of severities using modern stents and high pressure inflation technique to reach a visually optimal result, the nominal stent size was never achieved mainly due to residual intrastent stenosis. If nominal stent size had been achieved, the results would have improved only marginally and would still be suboptimal in almost half of the stents. These results highlight the shortcoming of angiography and the need for intravascular ultrasound in choosing correct stent size.