Editorial Comment

Friction-Free Stenting

Joel K. Kahn, MD

Division of CardiologyDepartment of Internal MedicineWilliam Beaumont HospitalRoyal Oak, Michigan

In his recent bestsellerThe Road Ahead,Bill Gates refers to theability to practice commerce via computers without the usualhassles of conventional businesses as friction free capitalism.Whatwas felt to be essential a few years ago in business can be madeobsolete by streamlined and more efficient technology. In a similarvein, Antoniucci et al. [1] present important information that bringsus a step closer to friction-free stenting.The importance of coronary stenting for enhancing the safety

and acute procedural results of coronary interventions is undeni-able. At William Beaumont Hospital, the referral rate for emer-gency bypass surgery is routinely under 1% each month, the lowestever realized. The use of bailout stenting is responsible for most ofthat progress. Early regimens included aggressive anticoagulationprotocols usually including warfarin, and bleeding complicationswere frequent. The progress made by Colombo et al. [2] and othersdemonstrated that reliable results could be obtained withoutsystemic chronic anticoagulation and freed us of many of theconstraints imposed by the original regimens. The results obtainedby Antoniucci et al. [1] free us of even more friction by showingthat even with omitting intravascular ultrasound, reliable results areobtained. The in-hospital recurrent ischemia rate of 3% is excellentfor a group of patients with actual or threatened abrupt closure.

Vascular complications were infrequent. This real-world use ofstents without warfarin or ultrasound validates what many of ushave observed—they make life in the laboratory easier.The data from follow-up angiography are encouraging for a very

low occlusion rate and a low restenosis rate at 6 months when asingle stent is used for bailout. The data with multiple stentsindicate that further work is needed on optimizing the therapy oflong dissections. It will be interesting to look at data from singlelong stents in longer dissections to determine if they offer anyfollow-up advantage.The future generations of stents with heparin coatings and more

advanced pharmacological approaches should be exciting. We lookforward to advances in the reliable stenting of smaller andangulated vessels, including those involving side branches. I cansee the day when we will slip all kinds of implantable devices intovessels with little mechanical friction from improved deliverysystems and with little clinical friction from improved patient caremethodologies.

REFERENCES

1. Antoniucci D, Valenti R, Santoro GM, Bolognese L, Taddeucci E,Trapani M, Santini A, Fazzini PF: Bailout coronary stenting withoutanticoagulation or intravascular ultrasound guidance: Acute andsix-month angiographic results in a series of 120 consecutivepatients. Cathet Cardiovasc Diagn 41:14–19, 1997.

2. Colombo A, Hall P, Nakamura S, Almagor Y, Maiello L, Martini G,Gaglione A, Goldberg S, Tobis JM: Intracoronary stenting withoutanticoagulation accomplished with intravascular ultrasound guid-ance. Circulation 91:1676–1688, 1995.

Catheterization and Cardiovascular Diagnosis 41:20 (1997)

r 1997 Wiley-Liss, Inc.