Journal of Invasive Cardiology

On the contrary, the CRUISE (Can Routine Ultrasound Influence Stent Expansion) study10 demonstrated a significantly lower TLR in patients with IVUS-guided stenting compared to angiography guided stenting at 9-month follow-up (8.5% versus 15.3%; p < 0.05) (relative reduction of 44%). In this study, the use of IVUS allowed the operator to achieve optimal results, resulting in an even lower TLR than in the OPTICUS trial.7 In a study of 1,706 patients by Kasaoka11 using IVUS-guided stenting, the restenosis group was found to have a significantly smaller reference lumen diameter, smaller final MLD by angiography and smaller stent lumen CSA by IVUS. In lesions where IVUS guidance was used, the restenosis rate was 24%, as compared with 29% if IVUS was not used (p < 0.05).

See Johansson et al. in this issue on pages 221–226

One of the major limitations to obtain appropriate stent expansion is the presence of plaque behind the stent and occasionally the presence of calcium or fibrosis which impair distensibility of the vessel wall.12 Balloon catheters, traditionally used as a first choice, inflate and expand in an asymmetric and inequitable fashion, particularly in the presence of calcified plaques.13 The frequent impossibility to obtain the expected result has limited the usage of IVUS as a tool to optimize stent expansion. For practical reasons, the most frequently used approach is to perform final stent dilatation with the increase in the balloon size.

In this issue of the Journal, the article by Johansson et al.14 deals with this idea of a systematic alternative approach. Stents could be deployed using angiography only — as it is the case at the present time, but using a standardized stent “over-dilatation” this goal could be achieved by an increment of 0.25 mm in balloon size, and high balloon pressure (16.1 ± 1.7 atm) for final stent deployment. An IVUS evaluation in all 37 studied lesions was done as well to document the optimize results with this technique. Compared to a historical group of patients, the standardized over-dilation achieved a larger MLD (3.0 ± 0.4 mm versus 2.7 ± 0.4 mm; p = 0.03), more stents achieved a minimal lumen area (MLA) of > 9 mm2 (46% versus 11%; p = 0.02) and more patients fulfilled AVID (Angiography-directed Versus Ivus-Directed coronary stent placement) study criteria for stent expansion (70% versus 32%; p = 0.048). Although there were no acute complications, no stents achieved a nominal size in spite of over-dilatation, and no differences in clinical variables were seen at 1-year follow-up. Thus, what is the value of this study?