Intravascular Imaging for Stent Failure - Current Status and Future Perspectives

Abstract Purpose of Review The scope of this review is to provide an up-to-date overview of the current evidence on the role of intravascular imaging (IVI) in the diagnosis, management and outcomes of patients presenting with stent failure and to highlight evidence gaps and future perspectives in this field. Recent Findings Based on the results of several large, randomized, prospective trials, there is convincing evidence to support IVI imaging guidance of percutaneous coronary intervention (PCI) procedures, particularly in the setting of complex coronary lesions, in order to reduce the occurrence of hard clinical endpoints, including cardiac death, target lesion revascularization and stent failure. On the other hand, due to their ability to identify underlying mechanisms leading to the occurrence of stent failure, current guidelines and consensus statements strongly advocate the use of IVI in this setting. However, specific evidence supporting this recommendation relies primarily on observational studies, of either prospective or retrospective nature, while randomized, prospective trials evaluating the prognostic value of IVI in the management of stent failure are virtually absent. However, based on findings of observational studies, several ongoing randomized trials, primarily in patients presenting with ISR, are evaluating the role of IVI in guiding treatment modalities, in an attempt to develop personalized IVI-based treatment approaches. Summary Despite the high performance of current-generation drug-eluting stents (DES), widespread adoption of PCI in patient cohorts characterized by increasing age and coronary lesion complexity contributes to the occurrence of stent failure, which is associated with substantial morbidity and mortality. Identifying and addressing the root causes leading to the occurrence of stent failure represent central, indispensable steps in the treatment of patients presenting with this condition, while coronary angiography has considerable intrinsic limitations in this regard. On the other hand, due to the high spatial resolution and improved ability to identify relevant pathogenetic mechanisms, incorporation of IVI modalities in the management of patients presenting with stent failure, has the potential to enable tailored therapeutic approaches, thereby personalizing treatment algorithms. Indeed, a growing body of evidence supports the use of IVI modalities as a tool to improve acute procedural results as well as to reduce the risk of recurrence in patients presenting with stent failure.