Well past a decade into the stent era, there's finally a growing recognition and furor over the costs and potential harms of unnecessary stenting. While interventional cardiologists are great for the bottom line of hospitals, a few high profile cases have demonstrated that PCI and stenting might be performed more than indicated.
And, not only is it costing those patients more in procedural billing, it's likely harmful to them as well.
This concept of "Fractional Flow Reserve" has been developing in cardiology literature to better evaluate whether a stenotic lesion is actually significantly impairing the perfusion of myocardium. These authors, part of a French cohort study called "DEFER," are following up prior studies showing FFR-guided selective stenting for left main disease is reasonable, and looking back at what they call "small vessel" coronary disease - LAD, RCA, and LCx.
This is, unfortunately, a retrospective analysis, and there are huge differences between the groups that underwent angiography-guided PCI and the group that underwent FFR-guided PCI - but not enough difference to account for the additional hazard ratio acquired by the angiography-guided PCI. Angiography-guided PCI, in their propensity-score adjusted hazard ratio, still had significant associations with increased non-fatal MI and future revascularizations during their five-year follow-up period. Indeed, the FFR-guided PCI group that did not find any vessels requiring intervention did outstanding - suggesting this perfusion-based strategy might be better for ensuring the benefits of stents do not outweigh the risks.
"Long-Term Clinical Outcome After Fractional Flow Reserve−Guided Percutaneous Coronary Revascularization in Patients With Small-Vessel Disease"