Management of Coronary Stent Underexpansion
- PMID: 39939043
- DOI: 10.1016/j.jacc.2024.12.009
Management of Coronary Stent Underexpansion
Abstract
Coronary stent underexpansion is an important problem and limitation of percutaneous coronary intervention, adversely affecting both short- and long-term patient outcomes. Stent underexpansion occurs when a stent fails to expand adequately compared with the adjacent reference segment, resulting in inadequate luminal gain. Multiple studies suggest that stent underexpansion is associated with increased risks of in-stent restenosis, stent thrombosis, and myocardial infarction, resulting in recurrent symptoms, readmissions, repeat interventions, and increased mortality. Contributing factors for stent underexpansion include severe calcification, inadequate lesion preparation, suboptimal stent deployment, and preexisting in-stent restenosis. Calcific plaques, especially when present behind a previously implanted, underexpanded stent, pose a significant challenge for further stent optimization. These lesions are often resistant to high-pressure balloon dilatation and may require advanced techniques that carry increased risks of complications. Intravascular imaging modalities, such as intravascular ultrasound and optical coherence tomography, have emerged as essential tools in diagnosing and managing stent underexpansion. These techniques provide a more detailed evaluation of the vessel and previously implanted stent, enabling the clinician to understand the exact mechanism of stent failure, and assess plaque burden and morphology, which ultimately helps guide appropriate treatment strategies. Despite the clinical importance of stent underexpansion, there is currently no consensus on its optimal treatment, largely because of the absence of large prospective studies in this area. This comprehensive review aims to summarize the existing evidence, clinical experience, and treatment strategies for coronary stent underexpansion, with the goal of providing practical guidance to clinicians to help optimize percutaneous coronary intervention and patient outcomes.
Keywords: in-stent restenosis; intravascular imaging; percutaneous coronary intervention; stent underexpansion.
Copyright © 2025 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Conflict of interest statement
Funding Support and Author Disclosures Dr Maehara has received consulting and speaking fees from Nipro and Boston Scientific. Dr Jaffer has received consulting and speaking fees from Medtronic, Magenta Medical, and Shockwave Medical; owns equity in Intravascular Imaging Inc, DurVena, and Fastwave; and has had research sponsored by Canon, Siemens, Shockwave Medical, Teleflex, Boston Scientific, and HeartFlow. Dr Doshi has received consulting fees from Abbott Vascular, ACIST, Asahi Intecc, Biotronik, Boston Scientific, Cordis, Medtronic, Penumbra, Philips, SIS Medical, Shockwave Medical, and Translumina. Dr Croce has received honoraria from Boston Scientific, Abbott, Teleflex, Abiomed, Takeda, Philips, and Cardiovascular Systems, Inc. Dr Bergmark has received research grants through the Brigham and Women’s Hospital from Pfizer, Amgen, Boehringer Ingelheim, Ionis, AstraZeneca, Inari, Philips, and Abbott Vascular; and has received consulting fees from Abiomed, CSI, Philips, Abbott Vascular, Endovascular Engineering, Shockwave Medical, Bain Life Sciences, SpectraWAVE, Terumo, Magenta Medical, and Boston Scientific. Dr Frizzell has received consulting fees and honoraria from Asahi Intecc, Boston Scientific, Medtronic, Reflow Medical, and Shockwave Medical. Dr Kirtane has received institutional funding to Columbia University and/or Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Amgen, CathWorks, Concept Medical, Philips, ReCor Medical, Neurotronic, Biotronik, Chiesi, Bolt Medical, Magenta Medical, SoniVie, and Shockwave Medical; has received research grants and institutional funding including fees paid to Columbia University and/or Cardiovascular Research Foundation for consulting and/or speaking engagements in which Dr Kirtane controlled the content; has equity options in Bolt Medical, and Airiver; and has received travel expenses/meals from Amgen, Medtronic, Biotronik, Boston Scientific, Abbott Vascular, CathWorks, Concept Medical, Novartis, Philips, Abiomed, ReCor Medical, Chiesi, Zoll, Shockwave Medical, and Regeneron. Dr McEntegart has received consulting fees from Boston Scientific and Shockwave Medical. Dr Brilakis has received consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, IMDS, Medtronic, and Teleflex; has received research support from Boston Scientific, and GE Healthcare; is an owner of Hippocrates LLC; and is a shareholder of MHI Ventures, Cleerly Health, and Stallion Medical. Dr Kearney has received consulting fees from Abiomed, Abbott Vascular, Boston Scientific, Medtronic, Teleflex, Philips and Cardiovascular Systems, Inc; and owns equity in Fastwave Medical. Dr Lombardi has received consulting fees from Asahi Intecc, Abiomed, Boston Scientific, Medtronic, Siemens, and Teleflex; receives royalties from Asahi Intecc; owns equity in Reflow Medical; and his spouse is a Reflow Medical employee. Dr Azzalini has received consulting fees from Teleflex, Abiomed, GE Healthcare, Reflow Medical, Shockwave, Abbott Vascular, and Cardiovascular Systems, Inc; has received a research grant by Abiomed; serves on the advisory board of Abiomed and GE Healthcare; and owns equity in Reflow Medical. Dr Ng has reported that he has no relationships relevant to the contents of this paper to disclose.
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