Catheterization and Cardiovascular Interventions 83:879–880 (2014)

Editorial Comment Is “the Bigger the Better” Still Valid for Drug-Eluting Stents? Vasileios F. Panoulas,1,2,3 MD, PHD, MRCP and Antonio Colombo,1,2* MD, FACC, FSCAI 1 Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy 2 Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy 3 National Heart and Lung Institute (Division of ICL), Imperial College London, London, United Kingdom

Even in the early days of bare metal stenting, minimum stent area (MSA) and stent length were shown to be independent predictors of in-stent restenosis (ISR) [1]. At that point in time, it seemed that the larger the post stenting MSA, and the shorter the stent the lower the incidence of ISR. The presentation and subsequent publication of the RAVEL study [2] shook the grounds by the absence of stent thrombosis and binary restenosis with the use of sirolimus drug-eluting stents (DES). Having a stent able to guarantee almost zero late loss appeared to liberate the operators from the need to maximize the acute gain. However, reality proved different: 10 years down the line restenosis is still with us with first- and even with second- and third-generation stents. Even though DES have reduced its incidence by reducing neontima hyperplasia [3], ISR leading to repeat target lesion revascularization remains the Achilles heel of percutaneous coronary intervention which is frequently flagged up in comparisons with coronary artery bypass surgery. This weakness is also reflected in the study design of the EXCEL (The Evaluation of XIENCE PRIME Everolimus Eluting Stent System (EECSS) or XIENCE V EECSS Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial which excluded repeat revascularization from its primary endpoint in an attempt to “assist” PCI to achieve noninferiority compared to surgery in patients with unprotected left main stem disease (or equivalent) and a SYNTAX score

Is "the bigger the better" still valid for drug-eluting stents?

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