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Editorial Comment
Two Stents Are Better Than One?
Joel K. Kahn, * MD
William Beaumont Hospital, Royal Oak, Michigan
The manufacturing of coronary stents that are, on the one hand,trackable, have excellent crossing profiles, and accommodatebends in the guiding catheter and artery and, on the other hand,provide excellent radial strength to avoid recoil has undoubtedlybeen a challenge to engineers. The demands of the coronaryvasculature have required stents with articulations and stents withrelatively low metal to artery wall coverage. Lederman andMoscussi [1] describe an example where conventional stentimplantation failed to overcome one particular threat to completearterial patency—elastic recoil of the stent by a resistant and elasticcoronary ostium. I have also experienced cases where standardstent delivery failed to achieve complete vessel patency due toprolapse of tissue through the articulation site. This can occur froma dissection flap or may be due simply to bulky atheromatousmaterial.
Lederman and Moscucci [1] are to be congratulated for demon-strating the potential benefit of extra metal in a coronary artery toovercome incomplete vessel expansion despite high pressureinflations. It is possible that a second coronary stent within theostium of the vessel may have been adequate to expand the ostium.
The authors chose a biliary stent to add extra metal withoutarticulation and with greater radial compressive force. It isunfortunate that intracoronary ultrasound was not performed. Itallowed us to more completely understand the lack of angiographicsuccess after the first stent was implanted in the ostium.
I have placed superimposed stents in situtations where eitherresidual atheromatous debris or a flap from a dissection haveobstructed the artery by protruding through the stent or articulationeven after complete coronary stent expansion with adequately sizedhigh pressure balloons. This approach has been quite satisfactory.
Alternatives to superimposed stenting include the possibility ofdebulking lesions more routinely before coronary stent delivery.Another approach would be to try prolonged balloon inflations iftolerated to try to mold the stent to the vessel wall. Finally, biliarystents can be used as the primary stent for difficult lesions likeostial right coronary narrowings.
I believe industry research dollars should be directed to thefeasibillity of providing stents with greater radial strength withinhighly trackable and pushable systems. Until then, it is good toknow that, at times, two stentsarebetter than one.
*Correspondence to: Joel K. Kahn, M.D., who is now at theMichigan Heart Group, P.C., 2221 Livernois, Suite 103, Troy, MI48083. E-mail: [email protected]
Catheterization and Cardiovascular Diagnosis 44:411 (1998)
r 1998 Wiley-Liss, Inc.
