In percutaneous coronary intervention, should long drug‑eluting stents be placed from normal segment to normal segment, or is it preferable to use short focal stents that cover only the diseased segment with a small healthy margin, considering the higher restenosis risk of long stents?

Stent Length Strategy in Percutaneous Coronary Intervention

Use longer stents to achieve complete lesion coverage from normal segment to normal segment, rather than short focal stents covering only maximum stenosis, as this approach reduces edge restenosis and improves long-term outcomes with modern drug-eluting stents. 1

Primary Recommendation: Normal-to-Normal Coverage

The most recent high-quality guidance from the Journal of the American College of Cardiology (2023) explicitly states that stent lengths should be selected to facilitate complete lesion coverage from the most normal distal segment to the most normal proximal segment 1. This represents a fundamental shift from older bare-metal stent strategies.

Critical Technical Requirements

When implementing normal-to-normal stenting, you must avoid these high-risk scenarios:

• Do not stent into reference segments with plaque burden >50%, as this dramatically increases edge dissection and edge restenosis risk 1
• Do not stent into segments with restricted lumen areas, particularly those with large lipid content or significant calcification 1
• Ensure <50% plaque burden within 5 mm proximal or distal to the stent edge as part of optimization criteria 1

The Drug-Eluting Stent Era Changes Everything

Your concern about "long stents likely to have increased restenosis" was valid in the bare-metal stent era but is no longer applicable with modern drug-eluting stents:

Evidence from Drug-Eluting Stent Trials

• The Rotterdam RESEARCH registry demonstrated that operators learned from earlier DES edge lesions to fully cover diseased segments, using mean stent length of 27.59 mm for mean lesion length of 17.48 mm, with only 11 restenosis cases (>50% diameter) among 841 stents, all occurring in focal patterns 1
• The E-SIRIUS trial showed sirolimus-eluting stents achieved only 5.9% binary restenosis even in long lesions (mean 15.0 mm) in small vessels, compared to 42.3% with bare-metal stents 2
• Drug-eluting stents demonstrate 6% vs 22% restenosis compared to bare-metal stents in left main disease 3

Bare-Metal Stent Data (Historical Context Only)

The older studies you're concerned about apply only to bare-metal stents:

• Each 10 mm of excess stent length increased percent diameter stenosis by 4.0% and target lesion revascularization (OR 1.12) with bare-metal stents 4
• Short bare-metal stenting (<10 mm) achieved 15.6% restenosis versus 24.4% with conventional longer stenting 5

These bare-metal stent principles are obsolete and should not guide modern DES practice 1.

Algorithmic Approach to Stent Length Selection

Step 1: Pre-Intervention IVUS/OCT Assessment

• Identify the true extent of diseased segments 1
• Measure plaque burden at potential landing zones 1
• Ensure landing zones have <50% plaque burden 1

Step 2: Select Stent Length

• Cover from normal distal to normal proximal segment 1
• Accept longer stent lengths to achieve complete coverage 1
• Avoid geographic miss (incomplete lesion coverage) 6

Step 3: Post-Deployment Verification

• Confirm no edge dissection involving media >3 mm length 1
• Verify adequate expansion (MLA >5.0 mm² or 90% of distal reference) 1
• Ensure complete lesion coverage in multiple angiographic views 6

Common Pitfalls to Avoid

Geographic Miss: Incomplete lesion coverage is a major cause of edge restenosis and adverse events. The 2023 JACC guidelines emphasize that postprocedure imaging must exclude geographic miss 1.

Stenting into Diseased Segments: The single most important technical error is landing stent edges in segments with high plaque burden (>50%), significant calcification, or large lipid pools, which causes edge dissection and edge restenosis 1.

Applying Bare-Metal Stent Logic: Do not use the "shortest stent possible" strategy from the bare-metal era. The 2006 ACC/AHA guidelines document that operators specifically learned to use longer stents with DES to fully cover diseased segments 1.

Special Considerations

Small Vessels

Even in vessels 2.5-3.0 mm diameter with long lesions (mean 15 mm), drug-eluting stents achieve excellent results with complete coverage, with only 4.0% requiring target lesion revascularization at 9 months 2.

Left Main Disease

For ostial and midshaft left main lesions, complete coverage achieves restenosis rates of only 1.7% versus 10.9% for bifurcation lesions 6.