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The “angioplastically correct” follow up strategy after stent implantation
  1. Department of Cardiology
  2. Pôle Cœur Poumon
  3. CHU Jean-Minjoz
  4. Boulevard Fleming
  5. 25030 Besançon Cedex
  6. France

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Over the last few years, the technique of percutaneous transluminal coronary angioplasty (PTCA) has undergone great change. The use of atherectomy has become marginal, and stent implantation almost systematic, justified by both a better outcome and a better cost:effectiveness ratio.1 ,2 Even the provisional use of stents seems to be less effective and more expensive than systematic stenting.3 Continuing advances in technology have more or less made the preliminary balloon predilatation unnecessary, leading to a technique now known as “direct stenting”. In this way, coronary angioplasty can increasingly be classified as simply stent implantation, a simple, safe, and rapid procedure. Furthermore, a consensus has progressively appeared regarding the follow up strategy and the indications for target vessel revascularisation (TVR), no longer based on the angiographic six month control, but rather only on symptoms and non-invasive detection of ischaemia, constituting an “angioplastically correct” follow up strategy. The difficulty of effectively treating in-stent restenotic lesions, the gap between angiographic restenosis and clinical outcome, the “oculo-stenotic” reflex, and the practical impossibility of systematic angiographic control are some elements which form the basis of the current follow up strategy. Nonetheless some exceptions to this “angioplastically correct” attitude should be debated.

Difficulty of treating in-stent restenotic lesions

Quasi-systematic stenting has at least one negative consequence: in-stent restenosis is going to become the main, if not the only, form of restenosis, and management of such lesions is reputed to be more difficult than post-PTCA restenosis. Percutaneous revascularisation is feasible, but after PTCA, the risk of a second restenosis is quite high, between 25–50%, mainly depending on the length of the lesion and the elapsed time before its occurrence.4 ,5 Despite this limited efficacy, balloon angioplasty remains the most frequently used strategy, treating focal (< 10 mm …

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