Predilatasyon Vs Direkt Stentleme: Hangi Lezyonda Ne Zaman?
Özet
Koroner arter hastalıklarının tedavisinde perkütan koroner girişim ve stent implantasyonu, günümüzde en yaygın revaskülarizasyon yöntemlerinden biri olarak öne çıkmaktadır. Stent implantasyonu öncesinde iki yaklaşım tercih edilmektedir: predilatasyon ardından stentleme (PS) ve doğrudan stentleme (DS). PS, balon dilatasyonu ile lezyonun hazırlanmasını sağlayarak stentin hedef bölgeye daha kolay ilerlemesine ve homojen açılımına zemin hazırlar; aynı zamanda rezidüel stenoz, disseksiyon ya da akım bozukluğu gibi bulguların ortaya konulmasına olanak tanıyarak ileri tekniklerin gerekliliğini gösterebilir. Bununla birlikte, ek işlem basamağı prosedür süresini ve kontrast yükünü artırdığı gibi komplikasyon riskini de yükseltebilir. DS ise balon aşamasını atlayarak işlemi basitleştirir, süreyi kısaltır ve kontrast-radyasyon maruziyetini azaltır; bu nedenle özellikle STEMI veya hemodinamik instabilite gibi acil senaryolarda avantajlıdır. Ayrıca balona bağlı intimal travma ve distal emboli ihtimalini ortadan kaldırır. Ancak uzun, kalsifik, tortiyöz veya bifürkasyon lezyonlarında yetersiz ekspansiyon ve malappozisyon riski belirginleşir. Strateji seçimi; hastaya ait klinik özellikler (ör. diyabet, böbrek fonksiyon bozukluğu, frajilite), lezyon morfolojisi (uzunluk, kalsifikasyon, tortiyozite, bifürkasyon, ostial tutulum), mevcut cihaz teknolojileri (stent profili, balon çeşitleri, aterektomi ve intravasküler görüntüleme) ve operatör deneyimi bir arada değerlendirilerek yapılmalıdır. Güncel ince strutlu stentler, gelişmiş balon teknolojileri ve görüntüleme yöntemleri her iki stratejinin de güvenli uygulanabilirliğini artırmış olup, sonuç olarak PS ve DS girişimsel kardiyolojide birbirini dışlamayan, uygun hasta ve lezyona göre tamamlayıcı yaklaşımlar olarak değerlendirilmektedir.
Referanslar
Ijsselmuiden AJ, Tangelder GJ, Cotton JM, et al. Direct coronary stenting compared with stenting after predilatation is feasible, safe, and more cost-effective in selected patients: evidence to date indicating similar late outcomes. Int J Cardiovasc Intervent. 2003;5(3):143-150. doi:10.1080/14628840310017807.
Martínez-Elbal L, Ruiz-Nodar JM, Zueco J, et al. Direct coronary stenting versus stenting with balloon pre-dilation: immediate and follow-up results of a multicentre, prospective, randomized study. The DISCO trial. DIrect Stenting of COronary Arteries. Eur Heart J. 2002;23(8):633-640. doi:10.1053/euhj.2001.2893.
Wilson SH, Berger PB, Mathew V, et al. Immediate and late outcomes after direct stent implantation without balloon predilation. J Am Coll Cardiol. 2000;35(4):937-943. doi:10.1016/s0735-1097(99)00639-7.
Hildick-Smith D, Arunothayaraj S, Stankovic G, Chen SL. Percutaneous coronary intervention of bifurcation lesions. EuroIntervention. 2022;18(4):e273-e291. Published July 22, 2022. doi:10.4244/EIJ-D-21-01065.
Fujino A, Mintz GS, Matsumura M, et al. A new optical coherence tomography-based calcium scoring system to predict stent underexpansion. EuroIntervention. 2018;13(18):e2182-e2189. Published April 6, 2018. doi:10.4244/EIJ-D-17-00962.
Ökmen E, Çam N. Direct Stent Implantation: Feasibility, Advantages and Disadvantages. Anatol J Cardiol. 2002;2(3):237-243.
Barbato E, Marco J, Wijns W. Direct stenting. Eur Heart J. 2003;24(5):394-403. doi:10.1016/S0195-668X(02)00802-3.
W.Vogel RF, Delewi R, Wilschut JM, et al. Direct stenting versus stenting after predilatation in STEMI patients with high thrombus burden: a subanalysis from the randomized COMPARE CRUSH trial. Eur Heart J. 2022;43(Suppl 2):ehac544.2068. doi:10.1093/eurheartj/ehac544.2068
Lozano I, López-Palop R, Pinar E, et al. Implante de stent directo sin predilatación: experiencia de un centro en 1.000 lesiones [Direct Stenting without Predilation: a Single-Center Experience with 1,000 Lesions]. Rev Esp Cardiol. 2002;55(7):705-712. doi:10.1016/s0300-8932(02)76688-8.
Konigstein M, Ben-Yehuda O, Redfors B, et al. Impact of coronary artery tortuosity on outcomes following stenting: a pooled analysis from 6 trials. J Am Coll Cardiol Intv. 2021;14(9):1009-1018. doi:10.1016/j.jcin.2020.12.027.
Outcomes Comparison of Direct Stenting Versus Pre-Dilation in Percutaneous Coronary Intervention. Indus J Biosci Res. 2025;3(7):462-466.
Schultheiss HP, Grube E, Kuck KH, et al. Safety of direct stenting with the Endeavor stent: results of the Endeavor II continued access registry. EuroIntervention. 2007;3(1):76-81.
Jurado-Román A, Gómez-Menchero A, Nieves G, Martín-Moreiras J, Ocaranza R, Ojeda S, et al. Plaque modification techniques to treat calcified coronary lesions. Position paper from the ACI-SEC. REC Interv Cardiol ES. 2023;5(1):46-61. Published March 18, 2024. Available from: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S2604-73062023000100008&lng=en. doi:10.24875/recic.m22000342.
Paolucci L, Shabbir A, Lombardi M, Jerónimo A, Escaned J, Gonzalo N. Management of stent underexpansion and aorto-ostial lesions. Interv Cardiol. 2024;19:e26. Published December 23, 2024. doi:10.15420/icr.2024.10.
Pan M, Lassen JF, Burzotta F, et al. The 17th expert consensus document of the European Bifurcation Club - techniques to preserve access to the side branch during stepwise provisional stenting. EuroIntervention. 2023;19(1):26-36. doi:10.4244/EIJ-D-23-00124.
Choudry FA, Weerackody RP, Jones DA, Mathur A. Thrombus embolisation: prevention is better than cure. Interv Cardiol. 2019;14(2):95-101. Published May 21, 2019. doi:10.15420/icr.2019.11.
Pradhan A, Bhandari M, Vishwakarma P, Sethi R. Deferred stenting for heavy thrombus burden during percutaneous coronary intervention for ST-elevation MI. Eur Cardiol. 2021;16:e08. Published March 30, 2021. doi:10.15420/ecr.2020.31.
Brilakis ES, Mashayekhi K, Tsuchikane E, et al. Guiding principles for chronic total occlusion percutaneous coronary intervention. Circulation. 2019;140(5):420-433. doi:10.1161/CIRCULATIONAHA.119.039797.
Verma B, Singh A, Saxena AK, Kumar M. Deflated balloon-facilitated direct stenting in primary angioplasty (the DBDS technique): a pilot study. Cardiol Res. 2018;9(5):284-292. doi:10.14740/cr770w. Epub October 7, 2018. PMID: 30344826; PMCID: PMC6188044.
Tamis-Holland JE, Abbott JD, Al-Azizi K, et al. SCAI Expert Consensus Statement on the management of patients with STEMI referred for primary PCI. J Soc Cardiovasc Angiogr Interv. 2024;3(11):102294. Published October 7, 2024. doi:10.1016/j.jscai.2024.102294.
Cosansu K, Ureyen CM, Vatan MB, Agac MT, Kilic H, Akdemir R. Impact of direct stenting on clinical outcomes for small vessel coronary artery disease in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction. Postepy Kardiol Interwencyjnej. 2019;15(4):404-411. doi:10.5114/aic.2019.90214. Epub December 8, 2019. PMID: 31933656; PMCID: PMC6956466.
Caluk F, Osmanovic E, Barakovic F, et al. Direct coronary stenting in reducing radiation and radiocontrast consumption. Radiol Oncol. 2010;44(3):153-157. doi:10.2478/v10019-010-0016-x.
Gebert ZM, Kwiecinski J, Weir-McCall JR, et al. Impact of diabetes mellitus on coronary artery plaque characteristics and outcomes in the SCOT-HEART trial. J Cardiovasc Comput Tomogr. 2025;19(2):208-214. doi:10.1016/j.jcct.2024.12.083.
Riley RF, et al. SCAI Expert Consensus Statement on the management of calcified coronary lesions. J Soc Cardiovasc Angiogr Interv. 2024;3(2):101259.
McCullough P. Contrast-induced acute kidney injury. JACC. 2008;51(15):1419-1428. doi:10.1016/j.jacc.2007.12.035.
Hennessey B, Shabbir A, Travieso A, et al. Procedural and technological innovations facilitating ultra-low contrast percutaneous coronary interventions. Interv Cardiol. 2023;18:e09. doi:10.15420/icr.2022.32.
Nanna M, Sutton N, Kochar A, et al. Assessment and management of older adults undergoing PCI, Part 1: A JACC: Advances Expert Panel. JACC Adv. 2023;2(4). doi:10.1016/j.jacadv.2023.100389.
Briguori T, Sheiban I, De Gregorio J, et al. Direct coronary stenting without predilation. J Am Coll Cardiol. 1999;34(7):1910-1915. doi:10.1016/s0735-1097(99)00453-2.
Mody R, Dash D, Mody B, Agrawal A, Monga IS, et al. Clinical outcomes of direct or direct-like stenting in patients undergoing primary PCI for STEMI. J Clin Cardiol Cardiovasc Interv. 2023;6(6). doi:10.31579/2641-0419/321.
Leone A, Simonetti F, Avvedimento M, et al. Ultrathin struts drug-eluting stents: a state-of-the-art review. J Pers Med. 2022;12(9):1378. Published August 25, 2022. doi:10.3390/jpm12091378.
Lee DH, de la Torre Hernandez JM. The newest generation of drug-eluting stents and beyond. Eur Cardiol. 2018;13(1):54-59. doi:10.15420/ecr.2018:8:2.
Shen X, Yi H, Ni Z. Effects of stent design parameters on radial force of stent. In: 2008 2nd International Conference on Bioinformatics and Biomedical Engineering; 2008; Shanghai, China. pp. 1712-1716. doi:10.1109/ICBBE.2008.756.
Drelich JW, Goldman J. Bioresorbable vascular metallic scaffolds: Current status and research trends. Curr Opin Biomed Eng. 2022;24:100411. doi:10.1016/j.cobme.2022.100411
Ng P, Maehara A, Kirtane AJ, et al. Management of Coronary Stent Underexpansion. J Am Coll Cardiol. 2025;85(6):625-644. doi:10.1016/j.jacc.2024.12.009
Byrne RA, Stefanini GG, Capodanno D, et al. Report of an ESC-EAPCI Task Force on the evaluation and use of bioresorbable scaffolds for percutaneous coronary intervention: executive summary. Eur Heart J. 2018;39(18):1591-1601. doi:10.1093/eurheartj/ehx488
Cuculi F, Bossard M, Zasada W, et al. Performing percutaneous coronary interventions with predilatation using non-compliant balloons at high pressure versus conventional semi-compliant balloons: insights from two randomised studies using optical coherence tomography. Open Heart. 2020;7(1):e001204. Published January 23, 2020. doi:10.1136/openhrt-2019-001204.
Burzotta F, Louvard Y, Lassen JF, et al. Percutaneous coronary intervention for bifurcation coronary lesions using optimised angiographic guidance: the 18th consensus document from the European Bifurcation Club. EuroIntervention. 2024;20(15):e915-e926. Published August 5, 2024. doi:10.4244/EIJ-D-24-00160.
Vrints C, Andreotti F, Koskinas KC, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes: Developed by the task force for the management of chronic coronary syndromes of the European Society of Cardiology (ESC). Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3415–3537. doi:10.1093/eurheartj/ehae177
Räber L, Mintz GS, Koskinas KC, et al. Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions. Eur Heart J. 2018;39(35):3281-3300. doi:10.1093/eurheartj/ehy285.
American College of Cardiology. Coronary interventions handbook – Chapter 1: coronary wires. ACC.org. Accessed 2025. Available from: https://www.acc.org/-/media/non-clinical/files-pdfs-excel-ms-word-etc/membership/coronary-interventions-handbook/chapter-1_coronary-wires.pdf.
Choi KH, Lee SY, Song YB, et al. Prognostic impact of operator experience and IVUS guidance on long-term clinical outcomes after complex PCI. JACC Cardiovasc Interv. 2023;16(14):1746-1758. doi:10.1016/j.jcin.2023.04.022.
Xu B, Redfors B, Yang Y, et al. Impact of operator experience and volume on outcomes after left main coronary artery percutaneous coronary intervention. JACC Cardiovasc Interv. 2016;9(20):2086-2093. doi:10.1016/j.jcin.2016.08.011.
Vogel RF, Delewi R, Wilschut JM, et al. Direct stenting versus conventional stenting in patients with ST-segment elevation myocardial infarction—A COMPARE CRUSH sub-study. J Clin Med. 2023;12:6645. doi:10.3390/jcm12206645.
Vizzari G, Laterra G, Mazzone P, et al. From single debulking techniques to combined approaches: a review of bailout strategies in heavily calcified coronary lesions. Vessel Plus. 2025;9:5. doi:10.20517/2574-1209.2024.59.
