Novel percutaneous therapies for complex coronary atherosclerosis

The remarkable improvements in techniques and technology have established coronary angioplasty as the dominant method of coronary revascularization in contemporary practice Despite the consequent improvement of the acute results due to the widespread use of stent implantation, restenosis and the need for repeat revascularization continues to hamper the efficacy of this strategy in the long term. The limitations of percutaneous intervention are more evident in patients with complex coronary artery disease. This term is difficult to define in rigorous scientific terminology. Complex coronary atherosclerosis includes patients with increased risk of future cardiovascular complications, and/ or complex 'anatomic' lesions. Recently, the use of the sirolimus-eluting stent has been associated with very promising results in reducing neointimal hyperplasia and restenosis rates Importantly, by maintaining the mechanical properties, the late benefit observed with drug-eluting stents was accomplished without compromising the excellent procedural and acute results already obtained with conventional metallic stents. The use of this strategy has been evaluated in large randomized trials with highly homogeneous selected populations usually consisting of simple lesions in large coronary vessels. Every day clinical practice of an interventional cardiologist differs, sometimes remarkably, from this "ideal world scenario". The patient with 'complex coronary artery disease' is usually not present in these trials. Yet these patients form the majority of the patients in our current clinical practice (Table). Evolving diagnostic modalities for coronary plaque imaging may help identify patients before cardiovascular events occur. The dream of every clinical cardiologist is to be able to prevent rather than treat acute coronary events. Therefore, the term "vulnerable patient" has been proposed to describe a group of patients whose management poses complex challenge. The term refers to patients at risk of an acute coronary event due to plaque, blood or myocardial vulnerability (Figure). Little is known regarding the variables that underlie each of these components of vulnerability or about the interactions among the