Intravascular ultrasound guided PTCA: a way to escape stent mania?

In 1995, a total of 278 982 percutaneous coronary interventions were carried out in Europe alone. In the United States, the corresponding figure for the same period was approximately 500 000, and these figures continue to increase worldwide, year after year. To date, plain old balloon angioplasty remains the strategy of choice in the majority of cases, even though a myriad of different devices have been conceived, developed and tested in percutaneous coronary interventions. However, up to now, no other single device has seen the same spectacular explosion on the market as the stent, and none has managed to oust the angioplasty balloon from its position at the top of the polls. Introduced in 1986, stents spread relatively slowly until the publication of large multicentre trials demonstrating the efficacy of this device in the prevention of restenosis. Since then, stents have spread like wildfire, and their diffusion has been all the more encouraged by improvements in the prevention of subacute occlusions. In 1997, the average rate of stenting in Europe was 51%, with figures ranging from 25% in Eastern Europe to more than 60% in Western European nations. Since this report was compiled, the rate of stenting has continued to grow, and is probably around 70% now. The most common indications for stenting are abrupt vessel closure, suboptimal result defined by residual stenosis >30%, coronary dissection of grade C or higher and treatment of restenosis on a native artery, not to mention the very broad indications for stenting in veinous bypass grafts. Without a doubt, stenting makes it possible to control abrupt occlusions and to optimize the result of the conventional angioplasty procedure. In short, the stent has made angioplasty safer and easier, with improved immediate results. However, it is worth noting that all these indications for stenting are based on observational studies only. The only indication in which the efficacy of stents has been proven is still complied with relatively rarely, namely the prevention of restenosis