J.Jpn. Surg. Soc.. 107(1): 3-8, 2006

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Feature topic

PCI: STATE OF THE ART

The restenosis issue which has not been resolved during the history of PCI is now being solved by drug eluting stent. In RAVEL trial which is a randomized control trial addressed to simple lesion, the restenosis rate was 0%. In SIRIUS trial addressed to more real world lesions, the restenosis rate was higher (8.9%) than expectation, especially the proximal margin restenosis was high (5.8%)．The new trials preventing the edge injury at the deployment could reduce the edge restenosis rate to 2.1%.
Because of the drastic decrease of restenosis rate, the indication of PC I is spreading to the lesions whose main problem is the restenosis before the DES era. They are diffuse diseases, small vessel diseases, bifurcation lesions, chronic total occlusions, instent restenosises and left main diseases in which superiority of DES for BMS is reported. Although there are no evidences so far, DES may have higher incidence of subacute and/or late stent thrombosis than BMS. Because the mortality of late stent thrombosis is high, antiplatelet therapy is considered to be continued for longer time.
In Japan, because the DES was introduced before the approval of clopidogrel, it was concerned about that incidence of thrombosis would be higher than other countries. In j-Cypher trial, a observational registry trial in Japan, revealed that the subacute thrombosis rate was lower level of the other studies and safety of DES utilization with ticlopidine based antiplatelet regimen.
There are no evidences that DES improves the long-term prognosis of the patients with coronary artery disease. Although in terms of the long-term prognosis in multivessel disease, PCI with BMS was comparable to CABG except for DM, ARTS II trial revealed the superior survival rate of DES at 1 year. The results of on going more real world trials are mandatory.

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