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Onea et al. Vessel Plus 2023;7:13 https://dx.doi.org/10.20517/2574-1209.2023.11 Page 3 of 12

Table 1. Risk factors for stent failure

Device and procedure-related Clinical-related

Long stents/stent overlap Premature DAPT discontinuation
Small vessel/stent diameter Diabetes mellitus
Complex lesion morphology (calcium++/bifurcations) Chronic kidney disease
Final TIMI flow < 3 History of PCI/bypass surgery/polyvascular disease
Stent undersizing/malapposition/underexpansion Hypersensitivity to polymer/drug
Stent fracture Active smoking
Thick struts HF with reduced EF
Stent gap Malignancy
Geographical miss
Edge dissection (especially if distal)
Uncovered struts
Neoatherosclerosis

DAPT: Dual antiplatelet therapy; EF: ejection fraction; HF: heart failure; PCI: percutaneous coronary interventions; TIMI: thrombolysis in
myocardial infarction.

Other factors independently associated with ISR include stent fracture, high stent strut thickness, stent gaps
[13]
or geographical miss , as well as clinical conditions such as diabetes mellitus (DM), chronic kidney disease,
[11]
and a history of CABG .
ST represents the other less frequent but more severe manifestation of stent failure, especially in the context
of an increasing number of complex PCI. While premature dual antiplatelet therapy (DAPT)
discontinuation is the strongest predictor of ST , other factors exist with different implications in early vs.
[14]
late ST. Obtaining good stent expansion is critical, as minimal stent area < 5.5 mm on optical coherence
2
tomography correlates with ST . Stent undersizing or malapposition, significant edge dissection (> 60°,
[15]
> 2 mm), and geographical miss are also associated with increased risks of ST. The persistence of uncovered
struts and neoatherosclerosis play a role in late ST .
[16]

LONG-TERM RESULTS OF STENTS IN DIFFUSE CORONARY ARTERY DISEASE
Although long and diffuse lesions represent a non-negligible entity in modern-day PCI, particularly with
the rising number of diabetic patients, large-scale studies on the clinical impact of newer DES are currently
lacking.

Very long-term follow-up (8 - 10 years) studies on first-generation DES reveal that stent length was already
identified as a predictor of treatment failure [17,18] . Data on newer-generation DES in the setting of diffuse
disease relies mainly on two large-scale registries. In the GRAND-DES registry, over 9,200 patients were
included and classified into two groups based on the length of stented segment. At long-term follow-up
(2 years), the primary endpoint of the study, TLF (a composite of cardiac death, target-vessel MI, and TLR),
occurred more often in the long-stent ( ≥ 40 mm) group (8.1% vs. 4.5%; P < 0.001). Additionally, cardiac
death (4.3% vs. 2.5%; P < 0.001), TLR (4.1% vs. 2.1%; P < 0.001) and early (P = 0.001) but not late ST rates
were also higher . Furthermore, Lee et al. identified specific cutoff points of stent length and diameter for
[19]
different stent types in predicting future poorer 3-year events [Figure 1]. A cutoff > 38 - 40 mm applied for