Drug-Eluting Stents and In-Stent RestenosisDrug-Eluting Stents and In-Stent Restenosis

To the Editor: From a practical standpoint, detailing the logistics required to administer the 600-mg clopidogrel pretreatment 2 hours before intervention, as was done in the study by Dr Kastrati and colleagues,¹ will be helpful, considering that in most centers patients with in-stent restenosis undergo ad hoc reintervention, and only complex cases are scheduled for staged procedures. In addition, it would be valuable to identify potential predictors of drug-eluting stent failure to provide early triage and, eventually, to divert patients to alternative techniques.^{2 - 4}

In this regard, although lesion length was not an exclusion criterion, the baseline median lesion length in the study was only 12 mm, and median stent length was twice as long. Therefore, knowing the criteria used to select stent length and the results of stent use in long lesions would be of major interest. Likewise, studies using intravascular ultrasound have demonstrated that drug-eluting stent underexpansion is a major predictor of late recurrences in this situation.⁵ Accordingly, assessing the prognostic influence of maximal pressure and selected balloon-to-vessel ratio would be important. In patients assigned to drug-eluting stent use, balloon predilatation was left to the operator’s discretion. It would be helpful to know if the results of direct drug-eluting stent implantation were similar to those obtained after predilatation, as well as the strategy selected for predilatation.