Percutaneous coronary intervention of specific coronary lesions

INTRODUCTION — Percutaneous coronary intervention (PCI) refers to both nonstenting procedures and stent interventions. Stenting represented an advance over balloon angioplasty (percutaneous transluminal coronary angioplasty [PTCA]) alone because acute procedural success was higher and the rate of restenosis requiring target lesion revascularization was much lower. Approximately 20 to 30 percent of patients required clinically driven repeat target lesion revascularization within the first year after PTCA alone compared with 10 to 15 percent with bare-metal stents (BMS) [1-3].

Drug-eluting stents (DES) represented a further advance in PCI and are now used in almost all procedures. In addition, newer-generation DES have replaced first-generation DES, owing to reduced restenosis and stent thrombosis. (See "Intracoronary stents: Stent types", section on '2012 comparison of drug-eluting stents' and "Percutaneous coronary intervention with intracoronary stents: Overview", section on 'Role for bare metal stents'.)

The use of PCI for specific coronary lesions will be reviewed here. The emphasis will be on the outcomes with DES. Issues related to the use of DES, the major clinical trials demonstrating the efficacy of DES compared to BMS, and the general principles of stent deployment are discussed separately. (See "Percutaneous coronary intervention with intracoronary stents: Overview".)

SPECIFIC CORONARY LESIONS

Left main and left anterior descending disease — Left main, left main equivalent, and proximal left anterior descending disease are associated with a relatively large amount of myocardium at risk. The possible indications for efficacy of drug-eluting stents (DES) with these lesions are discussed separately. (See "Management of significant proximal left anterior descending coronary artery disease", section on 'PCI versus CABG' and "Left main coronary artery disease", section on 'Feasibility and technical factors'.)

Multivessel revascularization — The role of intracoronary stents for patients with multivessel coronary artery disease (CAD) is discussed separately. (See "Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention" and "Coronary artery revascularization in stable patients with diabetes mellitus", section on 'PCI versus CABG'.)

Potential concerns — There are potential concerns with multivessel and complex lesion treatment with DES that may limit its use compared to coronary artery bypass graft surgery (CABG) [4]:

●A higher risk of early and late stent thrombosis (5 of 17 [29 percent] in one series) in patients who prematurely discontinue antiplatelet therapy with aspirin and clopidogrel [5]. (See "Coronary artery stent thrombosis: Incidence and risk factors".)

●A higher rate of repeat revascularization in patients undergoing PCI compared to CABG, especially in diabetic patients (12.6 versus 4.2 percent) [6]. (See "Coronary artery revascularization in stable patients with diabetes mellitus".)

●A greater likelihood that patients with PCI will have progressive coronary disease in areas not protected by stenting. In a review of 3747 PCIs from the National Heart, Lung, and Blood Institute Dynamic Registry, 216 (5.8 percent) required nontarget lesion PCI at one year; 87 percent of these nontarget lesions were ≤60 percent stenosis at initial PCI (mean 42 percent compared with 84 percent during the recurrent event) [7].

●A greater likelihood of incomplete revascularization (IR) with PCI compared with CABG, particularly in patients with decreased left ventricular systolic function [8].

●A higher risk of death and repeat revascularization in patients undergoing complete revascularization (CR) with PCI [9-11].

Complete versus incomplete revascularization — Older studies of CABG suggest that CR is better than IR [12]. It is unclear whether this concept from revascularization with CABG extends to revascularization with PCI. There are no trials comparing CR to IR in patients with a similar burden of CAD, and the conclusions of observational studies differ:

●Outcomes after CR and IR were compared in a single-center registry report of 1914 patients undergoing PCI (n = 1400) with DES or CABG (n = 514) for multivessel CAD [13]. CR was achieved in 41 and 67 percent of those receiving PCI or CABG, respectively. Using a definition of CR (applied to the diagnostic angiogram) as any attempt to revascularize all disease segments ≥1.5 mm, no significant difference was found between those with CR and those with IR in the adjusted rates of five-year death (8.9 versus 8.9 percent; adjusted hazard ratio [HR] 1.04, 95% CI 0.76-1.43 respectively) or the composite of death, myocardial infarction (MI), or stroke (12.1 versus 11.9 percent; adjusted HR 1.04, 95% CI 0.79-1.36). The results were similar for analyses performed on only those patients who underwent PCI.

●In a substudy of the SYNTAX trial, long-term rates of all-cause death were similar among patients randomly assigned to CABG who had CR or IR and patients assigned to PCI with a DES who had CR (23.8, 24.3, and 22.2 percent for CABG CR, CABG IR, and PCI CR, respectively) and higher in patients with PCI and IR (34 percent) [14]. Ten-year mortality rates were similar among patients who had CR with either CABG or PCI (adjusted HR 0.97; 95% CI 0.72-1.31). Regardless of random assignment to PCI or CABG, patients with less complete revascularization had a higher burden of CAD prior to revascularization (ie, SYNTAX score) and a higher prevalence of comorbidities, which may account for the higher mortality in patients with IR.

If a decision has been made to perform PCI rather than CABG in patients with refractory angina and multivessel disease, based on the available evidence, an attempt should be made to revascularize all lesions likely to impair coronary flow to moderate or large areas of viable myocardium. The results of noninvasive imaging techniques performed before PCI or the determination of fractional flow reserve during the procedure may be useful in this regard [15]. (See "Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention" and "Coronary artery revascularization in stable patients with diabetes mellitus", section on 'PCI versus CABG' and "Clinical use of coronary artery pressure flow measurements", section on 'Multivessel disease'.)

Ostial lesions — Ostial lesions respond poorly to conventional balloon percutaneous transluminal coronary angioplasty (PTCA) because of inadequate dilation and elastic recoil. Stents may be an excellent treatment for elastic recoil, but efficacy is uncertain if debulking is also required.

Implantation must be precise to avoid positioning the stent too proximally, while assuring adequate coverage of ostial disease. Lack of optimal positioning can result in stent protrusion into the aorta, which may make repeat catheterization difficult or increase the risk for thromboembolic complications.

Data are limited on DES for ostial lesions but the benefit appears to be similar to that seen with other lesions [16,17]. The best data come from the SCANDSTENT trial in which 322 patients with symptomatic complex CAD were randomly assigned to PCI with a sirolimus-eluting or bare-metal stent (BMS) [16]. Among the 73 patients with ostial lesions, target lesion revascularization by seven months occurred only with BMS (0 versus 35 percent). In our experience, DES of the right coronary artery ostium has been associated with a higher frequency of clinically significant restenosis relative to other locations.

Lesions at the origin of the left anterior descending artery were evaluated in a study comparing sirolimus stents in 68 consecutive patients with such lesions to 77 patients treated with BMS during the preceding two years [18]. Positioning of the sirolimus stent into the distal left main trunk was required in one-third of patients for complete lesion coverage. The sirolimus stent was associated with significant reductions in angiographic restenosis at six months (5 versus 32 percent with BMS) and target vessel revascularization at one year (0 versus 17 percent).

Chronic total occlusion — Chronic total occlusion (CTO) is defined as a 100 percent stenosis of a coronary artery with Thrombolysis In Myocardial Infarction (TIMI) 0 flow (table 1) for more than three months (based on angiography or symptoms) [19]. Severe (but not total) occlusions with impaired flow are often referred to as "functional" CTOs, but such lesions are often technically less challenging to address percutaneously given the presence of an antegrade channel [20]. The full discussion of CTO is found elsewhere. (See "Chronic total occlusion (CTO) in the coronary circulation".)

Long lesions or diffuse disease — Long stents or multiple stents may play an important role in the treatment of long lesions or diffuse disease. Restenosis rates are proportionally higher in longer lesions, but are lower than those associated with conventional PTCA. With BMS, longer stent segment length (>35 mm) is associated with an increased risk of restenosis [21]. Although DES reduce the rate of restenosis, stent length >35 mm is still a risk factor for restenosis [22].

Stent length should also be viewed in terms of lesion length. In the TAXUS IV trial of paclitaxel stents, the operators were instructed to choose stent lengths to cover the lesion by 2 to 4 mm at each margin. Using longer stent-to-lesion lengths beyond that required to achieve this goal was of no benefit [23]. In the SIRIUS trial, excess stent length was associated with an increased risk for restenosis; the absolute increase in follow-up diameter stenosis per 10 mm excess stent length was 3.6 and 2.1 percent for bare-metal and DES, respectively [24].

Overlapping stents — A potential concern with longer lesion treatment is that overlapping DES may result in adverse effects due to possible drug toxicity or polymer instability in the overlap segment. However, the use of multiple overlapping DES for very long lesions was relatively safe and associated with good intermediate-term outcomes in two small series [25,26].

In one of these reports, 66 patients with diffuse disease of the left anterior descending artery (average lesion length about 80 mm) were treated with multiple (mean 2.8) sirolimus or paclitaxel stents [25]. The following findings were noted:

●Angiographic and procedural success was achieved in 95 percent of patients.

●Eleven patients (17 percent) developed a non-ST-elevation MI in hospital, and one patient developed stent thrombosis.

●At follow-up angiography at six months in 52 patients, 10 (19.6 percent) had restenosis; most of the lesions were focal.

●At an average follow-up of 13.6 months, there were no deaths, one patient had a non-ST-elevation MI, 10 (15 percent) required target vessel revascularization, and one patient required CABG.

Overlapping stents are associated with greater late lumen loss and more frequent angiographic restenosis than single stents. However, a subset analysis from three randomized trials and two prospective observational studies comparing sirolimus to BMS found that the magnitude of the restenosis benefit of sirolimus stents was similar in overlapping and single stents [27].

Concerns have been raised about possible persistent inflammation and delayed reendothelialization at overlapping compared to nonoverlapping sites. A pathologic study in a rabbit iliac artery model of overlapping sirolimus and paclitaxel stents found evidence for increased inflammation and delayed healing for DES compared with BMS [28]. These changes were more pronounced at overlapping than nonoverlapping sites.

Very long lesions — The efficacy of DES for very long lesions (median 79 mm, range 64 to 168 mm) was evaluated in a series of 122 patients with de novo lesions; multiple overlapping stents were used (mean 3.3 per lesion), an approach that has been called "full metal jacket" [29]. Periprocedural MI occurred in two patients (1.6 percent). At one year, the overall rate of major adverse cardiac events was 18 percent, including target vessel revascularization in only 7.5 percent, nonfatal MI in 8.2 percent, and death in 4.1 percent. There was only one case of subacute stent thrombosis and the outcomes were similar with sirolimus and paclitaxel stents.

Bifurcation lesions — Complex bifurcation lesions in the coronary arterial circulation generally have the following characteristics [30,31]:

●They involve the origin of a coronary artery side branch that is ≥2.5 mm in diameter.

●The side branch lesion length is at least 10 mm.

●The side branch diameter stenosis is ≥70 percent.

●Calcification, if present, would likely require atherectomy for side branch treatment.

●The side branch bifurcation angle is <45 or >70 degrees.

It has been estimated that bifurcation lesions are present in 15 to 20 percent of lesions treated at the time of PCI [32]. These lesions are more difficult to treat due in part to differences in anatomic patterns of stenosis, variations in the diameter of each of the branches, and the angle at which the side branch comes off the main branch. Some lesions are particularly challenging and have been called complex coronary bifurcation lesions.

The degree of ostial side branch stenosis is the primary determinant of the need for side branch protection. Treatment of bifurcation lesions with stenting has been associated with an increase in early complications, including compromise of the branch vessel or the target lesion, with the potential for MI, and enhanced potential for restenosis involving either the parent vessel or side branch. In addition, stenting may impair access to the side branch.

PCI with DES is performed in most patients [33]. In selected patients, a debulking procedure or calcification modification treatment such as rotational atherectomy is combined with DES. (See "Specialized revascularization devices in the management of coronary heart disease".)

Main versus main plus side branch stenting — In most cases we suggest a strategy of main vessel only stenting with provisional stenting of the side branch ("provisional" approach) rather than a strategy of main plus side branch stenting, which has been referred to as "dedicated" or "complex" side branch stenting [34-37]. However, for patients with complex bifurcation lesions, a two-stent technique is a reasonable approach.

At least four randomized trials, each using somewhat different techniques, have compared these two approaches:

●In the TRYTON trial, 704 patients with bifurcation lesions were randomly assigned to a main vessel stent plus provisional stenting or a dedicated bifurcation stent [38]. The bifurcation stent, the Tryton Side Branch Stent, is a non-DES that requires implantation of a DES in the main branch to lock the device in place. At nine months, the rate of primary end point of target vessel failure (cardiac death, target vessel MI, and target vessel revascularization) was lower with provisional main vessel stenting (12.8 and 17.4 percent, respectively). The difference of 5.6 percent exceeded the pre-specified noninferiority margin for the bifurcation stent of 5.5 percent; the difference was primarily attributable to an increase in the rate of MI (10.1 versus 13.6 percent). In a subsequent single-arm registry and post-hoc analysis that was restricted to side branches >2.25 mm in diameter, the Tryton device met a pre-specified performance goal and has received United States Federal Drug Administration approval for use in these larger side branches [39].

●In the Nordic Bifurcation trial of 413 patients, there was no significant difference in the rate of major adverse cardiac events (MACE), defined as death, non-procedure-related MI, target vessel revascularization, or stent thrombosis, between the two-stent and provisional groups (3.4 versus 2.9 percent, respectively) at six months [35]. At five-year follow-up, freedom from MACE was not significantly different in the two groups (78.2 versus 84.2 percent, respectively) [40].

●In the CACTUS trial of 350 patients, there was no significant difference in the rate of MACE (death, MI, and target vessel revascularization) between a two-stent technique with "crush stenting" and provisional groups (15.8 versus 15 percent respectively) at six months [36].

●In the BBC ONE trial of 500 patients, the primary end point (a composite of death, MI, and target-vessel failure) occurred significantly more often in the multistent group (15.2 versus 8.0 percent; HR 2.20, 95% CI 1.17-3.47), attributable principally to a significantly higher rate of MI (11.2 versus 3.6 percent) at nine months [37].

In these trials, patients assigned to complex procedures had statistically longer procedure and fluoroscopy times, higher contrast volumes, and higher rates of procedure-related increases in biomarkers of myocardial injury. The rate of side branch stenting in the provisional group of these studies varied from 4 to 30 percent.

Based upon the available evidence, including the fact that most side branches have a normal fractional flow reserve and presumed good outcome irrespective of angiographic severity [41], we recommend a strategy of limiting stent implantation to the main vessel using a DES for patients with bifurcation lesions. Side branch stent placement is appropriate for significant dissection, reduced flow (TIMI flow less than grade 3; (table 1)), or clinical evidence of ischemia.

Patients who may benefit from a dedicated two-stent approach include those with complex bifurcation lesions [42]. (See "Left main coronary artery disease", section on 'Distal lesions'.)

The DEFINITION II trial randomly assigned 653 patients with complex bifurcation lesions to a two-stent technique or provisional stenting. For the two-stent techniques, the DK crush (78 percent) or culotte stenting methods were strongly recommended [43] (see 'Side branch stenting techniques' below). In DEFINITION II, 29 percent of lesions were in the distal left main coronary artery. The primary endpoint (a composite of target lesion failure at one-year follow-up, including cardiac death, target vessel MI, and clinically driven target lesion revascularization) occurred in 11.4 and 6.1 percent of the two groups, respectively (HR 0.53, 95% CI 0.30-0.90). The findings in DEFINITION II are consistent with other studies [42,44,45].

Final kissing balloon dilation — Although final kissing balloon inflation is always required with two-stent strategies, the issue of whether simultaneous balloon dilatation of both the main vessel and the side branch (final kissing balloon dilatation [FKBD]) is necessary after placement of a stent in only the main vessel was addressed in the Nordic-Baltic Bifurcation Study III [46]. In this trial, 477 patients with either stable or unstable disease and a bifurcation lesion were randomly assigned to either FKBD or no FKBD after stenting of the main vessel. Stenting of the side branch was allowed if, after FKBD, side branch TIMI flow grade was less than 3 (ie, less than normal flow which fills the distal bed completely).

At six months, there was no significant difference in the rate of the primary composite end point (cardiac death, non-procedure-related index lesion MI, target lesion revascularization, or definite stent thrombosis) between the FKBD and no FKBD groups (2.1 and 2.5 percent, respectively). As expected, based upon the experience comparing main versus main plus side branch stenting discussed in the preceding section, FKBD resulted in increased use of contrast media and longer procedure and fluoroscopy times. This is in contrast to dedicated two stent strategies, wherein FKBD is almost always advised.

We suggest FKBD in all two-stent approaches, but we suggest single-stent bifurcation treatment only in cases where there is reduced flow or other evidence of ischemic compromise involving a side branch that supplies at least a moderate myocardial territory.

Side branch stenting techniques — When the side branch is stented, many techniques have been utilized and are discussed in detail elsewhere [33].

Summarized briefly:

●The simplest is provisional side branch stenting, in which a single stent is placed in the main vessel, and balloon dilation or stenting of the side branch is performed only if branch compromise ensues.

●Pre-emptive stenting of both the main vessel and side branch, either by simultaneous inflation of the two stents side by side over a short distance proximal to the bifurcation (simultaneous kissing stents), "culotte" technique, in which a second stent is deployed through a strut of an initially placed stent in the parent vessel of side branch, overlapping the first stent for a short distance, or a variety of so-called "T" or "Y" techniques.

●In the crush technique, the proximal end of the stent in the side branch is crushed against the vessel wall as the second stent is deployed in the parent vessel in an attempt to optimize stent coverage of the entire plaque surface at the carina [30,47-49]. A final kissing balloon postdilation is essential and is performed by re-advancing a guidewire and angioplasty balloon through the sides of the parent vessel stent into the side branch and inflating simultaneously with a second balloon positioned within the parent stent. Most investigators have abandoned the basic technique due to lack of demonstrated benefit, possible increased safety concerns, and uncertainty of achieving final kissing balloon inflation in all cases. A modification of the technique has been developed using a two-step approach with one kissing inflation after initial stenting of the side branch and crush with a balloon in the main vessel and a second, or FKBD, after the main vessel stent is placed (the double kissing crush technique). As noted above, this technique has shown benefit over provisional stenting in complex left main CAD with true distal bifurcation stenosis involving both the left anterior descending and circumflex origins. (See "Left main coronary artery disease", section on 'Distal lesions'.)

There is no consensus which two-stent technique is preferred in the treatment of non-left main bifurcation lesions, since most trials have not shown a planned two-stent approach to be superior to stenting of the main branch and rescue of the side branch with balloon angioplasty as needed. It is our practice to avoid side branch stents whenever possible. Regardless of technique, we recommend final kissing balloon inflation for optimal stent deployment whenever side branch stenting is required. Development of specially designed bifurcation stents may offer promise in the treatment of these complex lesions.

Left main disease — Among patients with left main disease, a distal bifurcation lesion requiring a two-stent approach has been associated with higher rates of angiographic restenosis and target lesion revascularization after PCI with DES. This issue is discussed separately. (See "Left main coronary artery disease", section on 'Distal lesions'.)

Small coronary arteries — In general, and irrespective of the device used for PCI, the risk of restenosis after PCI is greater for small compared with large coronary arteries [50-52]. For most patients who need PCI of one or more lesions in a small coronary artery (≥2 to <3 mm), we use either a DES or a drug-coated balloon (DCB). DCBs are not available in the United States.

Randomized trials before the availability of DES suggested that BMS in small coronary arteries did not improve long-term outcomes compared to conventional balloon angioplasty, provided that dilatation produced a satisfactory initial result [53]. Stents were beneficial if the results of balloon angioplasty were suboptimal with a persistent significant residual stenosis. The efficacy of the first-generation sirolimus stent compared to BMS in small coronary arteries was evaluated in three randomized trials, E-SIRIUS, SES-SMART, and TAXUS V [54-56]. Relatively small studies of early-generation DES found that DES, compared with BMS, was associated with significant reductions in restenosis within the lesion ≥50 percent diameter (6 versus 42 percent) and the rate of target vessel revascularization (4 versus 21 percent).

Small studies have compared DCB with DES in small vessels [57-59]. In the BASKET-Small 2 all-comer population trial, 758 patients with de novo lesions less than 3 mm in diameter were randomly assigned to receive angioplasty with DCB or implantation of a second-generation DES [59]. After 12 months, there was no difference in the rate of the combined outcome of cardiac death, nonfatal MI, and target-vessel revascularization (7.5 versus 7.3 percent; HR 0.97, 95% CI 0.58-1.64; p-value for noninferiority 0.0217). Efficacy and safety of DCB were maintained for up to three years [60].

At least two newer generation DES designed for very small vessels have been approved [61,62].

Large coronary arteries — When evaluating outcomes in patients with large coronary arteries (≥3.0 mm in diameter), two points should be kept in mind:

●The rate of target lesion revascularization (TLR) is lower in large compared to small coronary arteries after stenting with either BMS or DES [63-66].

●In the broad population of patients who undergo PCI with stenting, DES reduce the rate of TLR compared with BMS, while the risks of death and MI are similar. (See "Intracoronary stents: Stent types", section on 'Bare metal stents'.)

In the subset of patients with large coronary arteries (≥3.0 mm in diameter), we believe evidence allows for the following conclusions regarding efficacy and safety comparing DES to BMS:

●The rate of TLR is equivalent or lower with DES compared to BMS [56,66,67], but the lower TLR rate in larger vessels makes the absolute benefits lower.

As the benefit from a reduction in TLR with DES compared with BMS declines in large vessels, any potential increase in risk associated with the use of DES becomes increasingly important. Retrospective analyses have raised the possibility of a possible increase in risk (cardiac death or MI) with DES in these vessels [67-69]. The BASKET-PROVE trial attempted to directly address this issue by randomly assigning 2314 patients needing stents 3.0 mm or greater in diameter to receive sirolimus-eluting stents, everolimus-eluting stents, or BMS [70]. While the rate of the primary end point (composite of death from cardiac causes or nonfatal MI at two years) was lower with the two DES (2.6 versus 3.2 versus 4.8 percent for sirolimus-eluting stents, everolimus-eluting stents, and BMS, respectively), these differences did not achieve statistical significance. This was due in part to unexpectedly low event rates, causing the trial to be underpowered to address the issue. Based on these data and evidence for improved safety and effectiveness for newer-generation DES in other lesions, we prefer DES over BMS in large vessels as long as DES can accommodate the vessel diameter.

Acute vessel closure or dissection — Stenting is the treatment of choice for either acute or threatened closure complicating PTCA and for the treatment of dissection; the goal is to restore TIMI 3 flow. In addition, acute or threatened closure may complicate predilation, stent deployment, or postdilation during a planned stent procedure and require the placements of additional stents to achieve optimal results. Failure to adequately restore flow or leaving untreated dissections significantly increases the risk for subacute thrombosis.

For treatment of acute closure or extensive dissections, the operator must consider other factors that may jeopardize the final result, including the relative size of the vessel, the inflow of blood into the treated segment, and the distal runoff. When either the flow into the artery or distal runoff is compromised, there is an increased risk for acute and subacute stent thrombosis, which may negate the beneficial effects of additional stenting. Smaller caliber vessels treated with smaller diameter stents also have an increased likelihood for subacute thrombosis compared to larger vessels treated with larger diameter stents.

Emergency surgery may be required in some situations, such as dissection of the left main artery or significant bifurcations, refractory thrombosis, loss of guide wire access, or inability to perform stenting.

SPECIFIC CLINICAL SETTINGS — In addition to their use for specific coronary artery lesions, intracoronary stents, particularly drug-eluting stents, have been used in specific clinical settings in addition with stable or unstable angina. Their efficacy in these settings is discussed elsewhere.

●Saphenous vein graft stenosis. (See "Coronary artery bypass graft surgery: Prevention and management of vein graft stenosis", section on 'Outcomes with PCI'.)

●In-stent restenosis. (See "Intracoronary stent restenosis", section on 'Choice of device'.)

●Primary percutaneous coronary intervention for ST-elevation MI. (See "Primary percutaneous coronary intervention in acute ST-elevation myocardial infarction: Periprocedural management", section on 'Selection of stent type'.)

●Non-ST-elevation acute coronary syndrome. (See "Non-ST-elevation acute coronary syndromes: Selecting an approach to revascularization".)

●Diabetic patients. (See "Coronary artery revascularization in stable patients with diabetes mellitus", section on 'Stent type'.)

●Women. (See "Management of coronary heart disease in women".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Percutaneous coronary intervention".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Beyond the Basics topic (see "Patient education: Stenting for the heart (Beyond the Basics)")

SUMMARY

●Introduction – Drug-eluting stents (DES) are now used almost exclusively in percutaneous coronary intervention (PCI) procedures, as they significantly reduce the risk of target lesion revascularization compared with bare-metal stents. (See "Percutaneous coronary intervention with intracoronary stents: Overview", section on 'Role for bare metal stents'.)

●Benefits of percutaneous coronary intervention – This benefit of DES has been demonstrated in a broad array of lesion types including multivessel, ostial, chronic total occlusion, and long lesions, as well as in small coronary arteries. However, coronary artery bypass graft surgery should be considered in some patients such as those with a high risk of coronary artery stent thrombosis and lesions that cannot be adequately revascularized with PCI, as well as some patients with diabetes or left main coronary artery disease. (See 'Specific coronary lesions' above.)

●Specific clinical settings – In addition to specific lesion types, DES are of benefit in specific clinical situations such as in patients with diabetes, acute coronary syndromes, vein graft lesions, and in-stent restenosis. (See 'Specific clinical settings' above.)