Direct Drug-Eluting Stenting to Reduce Stent Restenosis: A Randomized Comparison of Direct Stent Implantation to Conventional Stenting With Pre-Dilation or Provisional Stenting in Elective PCI Patients

Study Questions:

What is the benefit of direct stenting in patients treated with drug-eluting stents (DES)?


The STRESSED (direct Stenting To reduce REStenosis in Stent Era with Drug elution) study authors randomized a total of 600 patients with angina pectoris or recent myocardial infarction to a strategy of direct stenting (DS), conventional stenting (CS; stenting after pre-dilation), or provisional stenting (PS). The primary endpoint was the mean minimal lumen diameter at 9-month follow-up angiography. Secondary endpoints were clinical procedural success defined as angiographic success without in-hospital major adverse cardiac events (MACE), and MACE at 9-month and 2-year follow-up.


Percutaneous coronary intervention (CI) was successful in 99% of patients. Stent implantation in the DS group was 98%, 99% in the CS group, and 77% in the PS group. The minimal lumen diameter at 9 months was similar between the three groups (2.12 ± 0.58 mm in the DS arm, 2.17 ± 0.67 mm in the CS arm, and 1.99 ± 0.69 mm in the PS arm). Restenosis at 9 months was 3.4% with DS, 6.7% with CS, and 11.5% with PS, p = 0.025. In the PS group, no stent was implanted in 23% of the patients. In this group, restenosis occurred in 32% at 9-month follow-up. In the 77% of PS patients in whom a stent was implanted, the rate of restenosis was 5%. There was no difference in 9-month MACE (6.8% with DS vs. 4.6% with CS and 7.5% with PS) or 2-year follow-up (11.5% with DS vs. 10.3% with CS and 13.8% with PS, p = 0.536).


The authors concluded that direct DES implantation compared with conventional DES implantation did not reduce restenosis. In addition, PS was associated with a higher rate of restenosis, but this did not translate into a difference in the rate of MACE.


This study demonstrates that both DS as well as CS using DES have excellent intermediate- and long-term results. This suggests that either approach can be considered based on the specific clinical scenario and the lesion characteristics. Currently, there is little to recommend one approach over another, and I personally remain in favor of CS as the default strategy.

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