When should a stent be placed during percutaneous angioplasty?

When is Stenting Indicated During Angioplasty?

Stenting should be preferred over balloon angioplasty alone during percutaneous coronary intervention (PCI), as it reduces the risk of abrupt closure, re-infarction, and repeat revascularization 1.

Primary Indications for Stenting

Coronary Artery Disease

Stenting is the standard approach for coronary PCI rather than an exception. The 2014 ESC/EACTS guidelines explicitly state that stenting should be preferred over balloon angioplasty in the setting of primary PCI 1. This represents a fundamental shift from earlier practice where balloon angioplasty was attempted first.

Specific Coronary Scenarios:

• ST-Elevation Myocardial Infarction (STEMI): Stenting is the preferred strategy during primary PCI, with new-generation drug-eluting stents (DES) showing superiority over bare-metal stents (BMS) in reducing major adverse cardiovascular events 1

• Acute Coronary Syndromes (ACS): All patients undergoing PCI with stenting require dual antiplatelet therapy (DAPT) for at least 12 months 2

• Non-ACS indications: DES should be used with clopidogrel 75 mg daily for at least 12 months if patients are not at high bleeding risk 2

Selective Stenting Indications (Bailout Situations)

While coronary stenting is now standard, in peripheral vascular interventions, stenting remains selective and indicated for:

1. Suboptimal Angioplasty Results

• Residual stenosis after balloon angioplasty
• Flow-limiting dissection
• Elastic recoil of the vessel 3

2. Acute Procedural Complications

• Abrupt vessel closure
• Significant dissection compromising flow 3

3. Angioplasty-Resistant Lesions

For peripheral vessels (iliac, central venous), stenting should be reserved for lesions that fail to respond adequately to balloon angioplasty alone 4, 3. Primary stenting in peripheral vessels does not show superior long-term patency compared to selective stenting 3.

Important Caveats and Contraindications

Patient Selection Considerations

Before placing any stent, patients must be counseled on the need for and risks of DAPT, and alternative therapies should be pursued if patients are unwilling or unable to comply with the recommended duration of DAPT 2. This is particularly critical for DES, which require prolonged antiplatelet therapy.

Bleeding Risk Assessment

If the risk of morbidity from bleeding outweighs the anticipated benefit of the recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (e.g., <12 months) is reasonable, or BMS may be preferred over DES 2.

Peripheral Vascular Disease Nuances

For iliac artery occlusive disease, the evidence suggests a more conservative approach:

• Primary angioplasty with selective stenting for failures shows equivalent long-term patency to primary stenting 3
• However, primary stenting in iliac artery occlusions may result in lower distal embolization rates compared to angioplasty alone 5

For central venous obstruction in hemodialysis patients, stenting should be reserved for angioplasty-resistant lesions, as primary angioplasty has significantly higher primary patency rates than stenting 4.

Practical Algorithm

1. Coronary PCI: Plan for stenting as the primary strategy (not bailout)
2. Ensure DAPT compliance: Verify patient can adhere to required antiplatelet regimen
3. Choose stent type: New-generation DES preferred for most indications
4. Peripheral vessels: Attempt angioplasty first; stent only for:
   • Inadequate angioplasty result
   • Flow-limiting dissection
   • Acute closure
   • Angioplasty-resistant lesions

Common Pitfalls to Avoid

• Incomplete stent deployment and undersizing should be avoided, particularly in STEMI where massive thrombotic burden is present 1
• Stacking anticoagulants: Patients treated with subcutaneous enoxaparin within 12 hours of PCI should not receive additional UFH during PCI 2
• Routine use of cutting balloon or laser angioplasty should not be performed during PCI 2