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  • Review Article
  • Published:

Stenting of complex lesions: an overview

Nature Reviews Cardiology volume 7, pages 485–496 (2010)Cite this article

Subjects

Abstract

Contemporary management of coronary artery disease relies increasingly on percutaneous techniques combined with medical therapy. Although percutaneous coronary intervention (PCI) can be performed successfully in most lesions, several difficult lesion subsets continue to present unique technical challenges. These complex lesions may be classified according to anatomic criteria, including extensive calcification, thrombus, and chronic occlusions, or by location, such as bifurcations, saphenous vein grafts and unprotected left main. PCI of these lesions often requires novel devices, such as drug-eluting stents, hydrophilic guidewires, distal protection balloons or filters, thrombectomy catheters, rotational atherectomy, and cutting balloons. An integrated approach that combines these devices with specialized techniques and adjunctive pharmacologic agents has greatly improved PCI success rates for these complex lesions.

Key Points

  • Percutaneous coronary intervention, combined with optimal medical therapy, is currently a safe, effective and reliable treatment option for millions of patients with coronary artery disease (CAD)

  • Substantial advances in interventional equipment, novel techniques and adjunctive devices have greatly expanded the scope of percutaneous coronary intervention to include many complex coronary lesion subsets

  • The percutaneous treatment of several types of coronary lesions remains challenging and is associated with increased risk of adverse outcomes

  • Multiple large-scale registries and subgroup analyses of randomized studies have shown similar outcomes following percutaneous or surgical revascularization of unprotected left main disease

  • Incorporating angiographic parameters of CAD severity, the SYNTAX score can be used to risk-stratify and identify the optimal revascularization approach for patients with complex CAD

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Figure 1: Two-stent approaches to bifurcation lesions.
Figure 2: Suggested approach for large bifurcation lesions on the basis of the size, angulation, and obstruction of the side branch.
Figure 3: Methods that facilitate wire crossing of a CTO.
Figure 4: Event rates in studies comparing CABG surgery and PCI in ULMCA disease.
Figure 5: For thrombotic lesions, EPDs can used to capture embolic debris before or after PCI.
Figure 6: Outcomes with adjunctive embolic protection devices for ST-segment elevation myocardial infarction in native vessels.

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Acknowledgements

Laurie Barclay, freelance writer and reviewer, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. Cardiac Catheterization Laboratory, Cardiovascular Institute, Mount Sinai Hospital, 1 Gustave L. Levy Place, Box 1057, New York, 10029, NY, USA

    Usman Baber, Annapoorna S. Kini & Samin K. Sharma

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  1. Usman Baber
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  2. Annapoorna S. Kini
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  3. Samin K. Sharma
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Contributions

U. Baber researched data to include in the manuscript. A. Kini and S. Sharma contributed to discussion of content for the article. U. Baber and A. Kini wrote the first draft of the article. S. Sharma reviewed and edited the manuscript before submission. U. Baber and S. Sharma revised the manuscript in response to the peer-reviewers' comments.

Corresponding author

Correspondence to Samin K. Sharma.

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Competing interests

The journal Chief Editor B. Mearns and the CME questions author L. Barclay declare no competing interests.

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Baber, U., Kini, A. & Sharma, S. Stenting of complex lesions: an overview. Nat Rev Cardiol 7, 485–496 (2010). https://doi.org/10.1038/nrcardio.2010.116

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