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Which is the role of post-dilation after DES implantation? Enrico Romagnoli 1,2 M.D., Ph.D. 1 Policlinico Casilino, Roma 2 Opedale San Raffaele, Milano Slide 2 Optimization of stent deployment during percutaneous coronary intervention (PCI) is a key element to obtain most favorable immediate and long-term results. Basic principle of stent-based PCI The bigger = The better Slide 3 Bigger stent expansion = better outcome Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. Circulation 1995;15;91:167688. Colombo A, et al. Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. Circulation 1995;15;91:167688. Conclusions : the Palmaz-Schatz stent can be safely inserted in coronary arteries without subsequent anticoagulation provided that stent expansion is adequate. High-pressure final balloon dilatations (14.9 3.0 atm) and confirmation of adequate stent expansion by intravascular ultrasound provide assurance that anticoagulation therapy can be safely omitted. This technique significantly reduces hospital time and vascular complications and has a low stent thrombosis rate (1.6%). Slide 4 Bigger DES expansion = better outcome? After the introduction of drug-eluting stents (DES), the importance of optimal stent deployment was initially underestimated, leading to less use of high pressure deployment and/or balloon post-dilation. Slide 5 Conclusion: SES had a considerably lower optimal MSA threshold compared to BMS Bigger DES expansion = better outcome? Cypher Bx Velocity Sonoda S, et al. J Am Coll Cardiol 2004 Slide 6 Hoffmann R,et al. Catheter Cardiovasc Interv 2005 A comparison study between SIRIUS-US (pre- and post- dilation) and E-SIRIUS (direct stenting and non mandatory post-dilation) IVUS results showed that, although the less aggressive stent implantation in E-SIRIUS resulted in a relatively lower stent expansion, no detrimental effects were observed in major adverse cardiac events. Bigger DES expansion = better outcome? Slide 7 = edge restenosis Sakurai R, et al. Am J Cardiol 2005 Slide 8 Bigger DES expansion = better outcome? Sakurai R, et al. Am J Cardiol 2005 = edge restenosis Slide 9 Magnitude of suboptimal stent expansion Because stent under-expansion is poorly recognized by angiography, the real incidence of suboptimal stent deployment is likely to be underestimated. Slide 10 Before post-dilationAfter post-dilation Slide 11 Determinants of Suboptimal Stent Deployment 1. Stent undersizing (balloon to artery ratio