How do I properly deploy a coronary stent, including dual antiplatelet therapy (DAPT) loading, unfractionated heparin (UFH) anticoagulation, intracoronary nitroglycerin, intravascular ultrasound (IVUS) or optical coherence tomography (OCT) guidance for lesion measurement and stent sizing, correct positioning with appropriate landing zones, manufacturer‑recommended deployment pressure, high‑pressure post‑dilation with a non‑compliant balloon, and post‑procedure continuation of DAPT?

Coronary Stent Deployment Protocol

For optimal coronary stent deployment, administer aspirin 150-300 mg plus a P2Y12 inhibitor loading dose (prasugrel 60 mg or ticagrelor 180 mg preferred over clopidogrel 600 mg), anticoagulate with unfractionated heparin 70-100 IU/kg IV bolus, use intravascular imaging (IVUS or OCT) to guide sizing and confirm optimal expansion, deploy at manufacturer-recommended pressure, perform high-pressure post-dilation with a non-compliant balloon, and continue dual antiplatelet therapy for at least 12 months. 1

Pre-Procedure Antiplatelet Loading

Timing and Agent Selection

• Load with aspirin 150-300 mg orally (chewed) or 75-250 mg IV if not already on maintenance aspirin therapy 1
• Administer prasugrel 60 mg or ticagrelor 180 mg loading dose in the emergency department or catheterization laboratory for acute coronary syndrome patients 1
• For elective PCI, clopidogrel 600 mg should be given at least 2 hours before the procedure if same-day loading is necessary, though 300 mg given 6 hours prior or the day before is acceptable 1
• Prasugrel and ticagrelor are superior to clopidogrel for ACS patients and should be prioritized when no contraindications exist 1

Critical Contraindications

• Do not use prasugrel in patients with prior stroke/TIA (Class III: Harm) 1
• Consider dose reduction of prasugrel to 5 mg daily maintenance (not loading dose) in patients ≥75 years or <60 kg body weight 1

Procedural Anticoagulation

Unfractionated Heparin Dosing

• Administer UFH 70-100 IU/kg IV bolus when no GP IIb/IIIa inhibitor is planned 1, 2
• Reduce to 50-70 IU/kg if GP IIb/IIIa inhibitors are used 1
• Discontinue heparin immediately after the procedure - do not continue as a drip post-PCI 2

Alternative Anticoagulants

• Enoxaparin 0.5 or 0.75 mg/kg IV bolus is a reasonable alternative to UFH with potentially reduced bleeding risk 1
• Bivalirudin is another Class IIa alternative to UFH 1

Intravascular Imaging Guidance

IVUS or OCT Utilization

• IVUS is reasonable for left main coronary artery stenting guidance (Class IIa) 1
• Use intravascular imaging to assess lesion length, reference vessel diameter, and plaque characteristics for optimal stent sizing 1
• IVUS can determine mechanisms of stent restenosis or thrombosis when these complications occur 1
• For intermediate stenoses (50-70% diameter), fractional flow reserve (FFR) is reasonable to guide revascularization decisions rather than proceeding directly to stenting 1

Lesion Preparation

• Intracoronary nitroglycerin should be administered to prevent vasospasm and ensure accurate vessel sizing 1
• Rotational atherectomy is reasonable for heavily calcified lesions that cannot be adequately dilated before stent implantation 1
• Do not perform rotational atherectomy routinely for de novo lesions (Class III: No Benefit) 1

Stent Deployment Technique

Positioning and Deployment

• Position the stent with appropriate proximal and distal landing zones in healthy vessel segments identified by imaging 1
• Deploy at manufacturer-recommended pressure to achieve initial expansion 1
• Perform high-pressure post-dilation with a non-compliant balloon to optimize stent apposition and expansion 1
• Confirm optimal result with repeat intravascular imaging when used for guidance 1

Glycoprotein IIb/IIIa Inhibitor Use

• Reserve GP IIb/IIIa inhibitors (abciximab, eptifibatide, tirofiban) for bailout situations only - thrombus, slow flow, vessel closure, or very complex lesions 1
• In STEMI patients not pretreated with clopidogrel and receiving UFH, GP IIb/IIIa inhibitor administration is reasonable (Class IIa) 1
• Do not routinely administer GP IIb/IIIa inhibitors pre-catheterization laboratory in STEMI patients (Class III: No Benefit) 1

Post-Procedure Antiplatelet Management

Maintenance Dual Antiplatelet Therapy

• Continue aspirin 75-100 mg daily (lower doses preferred over higher doses) 1
• Prasugrel 10 mg daily or ticagrelor 90 mg twice daily for at least 12 months after drug-eluting stent placement 1
• For bare metal stents in non-ACS patients, clopidogrel 75 mg daily for minimum 1 month, ideally up to 12 months 1
• All ACS patients require 12 months of DAPT regardless of stent type 1

Duration Considerations

• If bleeding risk outweighs ischemic benefit, earlier discontinuation (<12 months) is reasonable (Class IIa) 1
• Do not implant drug-eluting stents if the patient cannot tolerate or comply with prolonged DAPT (Class III: Harm) 1
• Counsel patients on the need for and risks of DAPT before stent placement, and pursue alternative therapies (bare metal stents or balloon angioplasty) if compliance is uncertain 1

Extended Therapy Beyond 12 Months

• In high ischemic risk ACS patients with low bleeding risk who complete 12 months of DAPT, ticagrelor 60 mg twice daily plus aspirin may be considered for up to 36 months 1, 3
• Rivaroxaban 2.5 mg twice daily plus aspirin (after discontinuing the P2Y12 inhibitor) may be considered in select high ischemic risk patients 2
• Do not combine rivaroxaban with dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) outside of atrial fibrillation requiring anticoagulation 2

Critical Pitfalls to Avoid

Common Errors

• Never proceed with stenting without confirming patient ability to comply with DAPT duration - this is a Class III: Harm recommendation 1
• Do not continue heparin infusion post-procedure - this increases bleeding risk without benefit 2
• Avoid prasugrel in patients with prior stroke/TIA due to increased bleeding risk 1
• Do not use clopidogrel 300 mg loading dose for same-day PCI - the 600 mg dose is required for adequate platelet inhibition within 2 hours 1, 4
• When switching from clopidogrel to ticagrelor, administer the full 180 mg loading dose to avoid gaps in platelet inhibition 1, 5

Bleeding Risk Mitigation

• Use radial artery access as default to reduce vascular complications 1
• Adjust anticoagulant doses for body weight and renal function, especially in women and elderly patients 1
• Prescribe proton pump inhibitors for patients on DAPT with history of GI ulcer/hemorrhage, anticoagulant therapy, chronic NSAID use, or age ≥65 years with dyspepsia 1