Different treatment modalities for underexpanded stents-Effectiveness and outcomes: A practical guide

Underexpanded stents are a dreaded complication of percutaneous coronary intervention (PCI) and are a major predictor of stent thrombosis and in-stent restenosis. Lesion preparation and plaque modification before stent implantation are essential to prevent stent underexpansion and optimize the technical outcomes of PCI. Once stent underexpansion occurs, the treatment options are limited. New devices for the treatment of complex calcified lesions have emerged in the past few years, and experience has accumulated with their use in the treatment of underexpanded stents. This review aims to provide an evidence-based, practical summary of the approach to stent underexpansion, with particular attention to the expected luminal gain, complication rates, and technical nuances of various treatment options. These modalities include the ultrahigh pressure OPN noncompliant balloon, excimer laser coronary angioplasty, rotational and orbital atherectomy, and intravascular lithotripsy. The data gathered for each of these modalities and our experience in treating this complex condition were used to formulate a treatment algorithm for such cases.