Stent length and outcomes after drug-eluting stent placement: time to redefine long lesions
Long lesions have been defined as lesions of more than 20 mm in length, which significantly increased the risk of acute procedural complications and late restenosis after conventional balloon angioplasty 9,10. The use of BMSs significantly reduced the incidence of acute procedural complications and restenosis after PCI. However, stent length was strongly linked to the incidences of stent thrombosis and restenosis 11,12. Most studies reported an ~50% rate of restenosis in long lesions of more than 20 mm because of pronounced neointimal hyperplasia 11,12. The high restenosis rate was observed with multiple overlapping BMSs and single long BMSs, making stenting difficult as a primary therapeutic option for diffuse coronary artery disease. Although advances in device technology, implantation techniques, and antiplatelet therapy enabled long BMS implantation, the full coverage of long lesions with long BMSs is controversial. Therefore, long BMSs were mainly used to treat acute complications after PCI, such as long dissection.
The availability of DESs has a major influence on the patterns of revascularization for the treatment of obstructive coronary artery disease. The applicability of PCI continues to expand to more complex lesions such as long coronary lesions. Full lesion coverage with DESs is considered the preferred approach to minimize the risk of stent edge restenosis and the stented length is inevitably increased in the era of DESs. Early DES studies have shown that the risk of target lesion revascularization was significantly associated with total stent length 13. However, Choi et al. 14 reported that stent lengths of more than 32 mm was associated with poor clinical outcomes in patients with first-generation DESs, but not in those with newer-generation DESs. Bouras et al.15 also showed that in patients who received an everolimus-eluting stent, clinical outcomes at 1 year were not significantly different between those with very long lesions (>35 mm) and those with long lesions (>24 to <35 mm).