I find it intriguing when a respected pioneering interventional group report a part of their early registry experience following the release of an exciting new technology. The inherent constraints encountered when performing a first-in-man trial or a small pilot safety study or a larger prospectively randomized controlled multicenter trial are loosened a bit and we get a glimpse at what our impending real-world encounters might present. It is almost like reading the preface to a good book: you get a taste for what might happen, but you have to read the whole book to understand things clearly.
This report demonstrates that undersized Cypher sirolimus-eluting stents (SESs) can be aggressively postdilated with larger balloons and provides encouraging clinical and angiographic outcomes [1]. This is an important observation, not only for those of us involved in the early investigation of these stents who were handcuffed by limited inventory, but also looking to future use of this device for non-RAVEL, non-SIRIUS, more complex lesions. The authors clearly delineate potential pitfalls that may be encountered when using this overdilatation strategy. These include polymer disruption, edge dissections, accentuated vascular deep wall injury, and inadequate vascular surface drug delivery, a form of geographical miss not completely dissimilar from the concept realized during the brachytherapy days. We are also reminded of the potential benefits of this strategy recalling the "bigger is better" credo, except I doubt the authors would have enthusiastically used their strategy had appropriately larger-sized stents been made available at the time of this registry. These benefits may include better postprocedure luminal dimensions, less restenosis, less stent thrombosis, and perhaps most importantly in the drug-eluting stent world, better stent apposition to the vessel wall, enabling optimal drug delivery.
It is important to realize that during this study enrollment period, the operators' SES inventory choices than would be expected with bare metal stenting; how-