Ng Primero, Maehara Akiko, Kirtane Ajay J, McEntegart Margaret, Jaffer Farouc A, Doshi Darshan, Croce Kevin J, Bergmark Brian A, Frizzell Jarrod D, Brilakis Emmanouil S, Kearney Kathleen E, Lombardi William L, Azzalini Lorenzo
Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA.
Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA.
J Am Coll Cardiol. 2025 Feb 18;85(6):625-644. doi: 10.1016/j.jacc.2024.12.009.
Coronary stent underexpansion is an important problem and limitation of percutaneous coronary intervention, adversely affecting both short- and long-term patient outcomes. Stent underexpansion occurs when a stent fails to expand adequately compared with the adjacent reference segment, resulting in inadequate luminal gain. Multiple studies suggest that stent underexpansion is associated with increased risks of in-stent restenosis, stent thrombosis, and myocardial infarction, resulting in recurrent symptoms, readmissions, repeat interventions, and increased mortality. Contributing factors for stent underexpansion include severe calcification, inadequate lesion preparation, suboptimal stent deployment, and preexisting in-stent restenosis. Calcific plaques, especially when present behind a previously implanted, underexpanded stent, pose a significant challenge for further stent optimization. These lesions are often resistant to high-pressure balloon dilatation and may require advanced techniques that carry increased risks of complications. Intravascular imaging modalities, such as intravascular ultrasound and optical coherence tomography, have emerged as essential tools in diagnosing and managing stent underexpansion. These techniques provide a more detailed evaluation of the vessel and previously implanted stent, enabling the clinician to understand the exact mechanism of stent failure, and assess plaque burden and morphology, which ultimately helps guide appropriate treatment strategies. Despite the clinical importance of stent underexpansion, there is currently no consensus on its optimal treatment, largely because of the absence of large prospective studies in this area. This comprehensive review aims to summarize the existing evidence, clinical experience, and treatment strategies for coronary stent underexpansion, with the goal of providing practical guidance to clinicians to help optimize percutaneous coronary intervention and patient outcomes.
冠状动脉支架扩张不足是经皮冠状动脉介入治疗的一个重要问题和局限性，对患者的短期和长期预后均产生不利影响。当支架与相邻的参考节段相比未能充分扩张时，就会发生支架扩张不足，导致管腔增益不足。多项研究表明，支架扩张不足与支架内再狭窄、支架血栓形成和心肌梗死风险增加相关，会导致症状复发、再次入院、重复干预以及死亡率增加。支架扩张不足的促成因素包括严重钙化、病变预处理不充分、支架植入不理想以及既往存在的支架内再狭窄。钙化斑块，尤其是存在于先前植入的、扩张不足的支架后方时，对进一步优化支架构成重大挑战。这些病变通常对高压球囊扩张有抵抗性，可能需要采用有更高并发症风险的先进技术。血管内成像方式，如血管内超声和光学相干断层扫描，已成为诊断和处理支架扩张不足的重要工具。这些技术能对血管和先前植入的支架进行更详细的评估，使临床医生能够了解支架失败的确切机制，并评估斑块负荷和形态，最终有助于指导合适的治疗策略。尽管支架扩张不足具有临床重要性，但目前对于其最佳治疗方法尚无共识，这主要是因为该领域缺乏大型前瞻性研究。这篇综述旨在总结冠状动脉支架扩张不足的现有证据、临床经验和治疗策略，目的是为临床医生提供实用指导，以帮助优化经皮冠状动脉介入治疗及患者预后。
