Original: Direct drug-eluting Stenting to reduce stent reestenosis (STRESSED). Reference: Wouter S. Remkes et al. J Am Coll Cardiol Intv, 2014;7: 751-8.

Direct stenting, without predilation, has been considered a safe and effective technique that reduces procedural time, radiation exposure, contrast material and costs; however, the pertinent studies tested conventional stents only. 

This study aimed at assessing whether DES direct implantation is associated with less restenosis than DES implantation with predilation.

It included 600 patients, younger than 85, with stable angina or recent unstable angina, with type ACC/AHA A, B1 and B2 lesions, non-calcified, and +50% to -100% restenosis. It did not include patients with bifurcation, ostial or left main lesions or with severe ventricular or renal failure. It used second generation zotarolimus or everolimus eluting stents.

Patients were randomized to 3 groups: direct DES stenting, DS (n=198); DES stenting with predilation, CS (n=201); and provisional DES stenting, PS (n=201).

Primary end point was minimal lumen diameter measured by quantitative angiography at 9 months and the secondary end point was a combination of death, infarction and revascularization during hospitalization, at 9 months and 2 years. 

Procedural success was 99% in both groups. Minimal lumen diameter at 9 months was 2.12mm (DS), 2.17mm (CS) and 1.99mm (PS); and restenosis was 3.4% (DS), 6.7% (CS) and 11.5% (PS).  MACE at 9 months and 2 years occurred in 6.8% and 11.5% (DS), 4.6% and 10.3% (CS) and 7.6% and 13.8% (PS), respectively.

Conclusion

Direct DES stenting did not reduce restenosis compared to DES stenting with predilation. Provisional stenting was associated with greater restenosis. MACE during follow up did not show significant differences between the three groups.

Editorial Comment

This study included the provisional stent group as a follow up to DIRECT-2, which used the same design to test conventional stents. Its outcomes matched the expectations for this group, since 23% of patients did not receive a stent. The direct stenting group was expected to show a reduction in restenosis since lesions were less complex and this technique has several advantages. Further analysis of both techniques with a larger population is still required.

Courtesy of Dr. Alfonso Francisco Balaguer Quiroga
Interventinal Cardiologist 
International Clinique. Lima, Perú.

Alfonso Francisco Balaguer Quiroga