An atherosclerotic plaque is termed vulnerable when it’s future behavior is unpredictable .A vulnerable plaque has a tendency to get occluded at any time.
Anatomically a vulnerable is present , if the lipid core is more , fibrous cap is thin and a large lipid core hanging eccentrically. A plaque with high temperature (Hot plaques ,febrile plaques)detected by OCT/Raman spectroscopy or thermography
What is the best method to calm down these vulnerable , hot ,inflamed plaques ?
A stent which scaffolds a plaque is believed to stabilse it and make it less vulnerable to rupture. This is the most optimistic view on coronary stenting .
Here comes a pessimistic view !
A metal inside a coronary artery covering is additional threat .A metal is perennially thrombogenic ,especially the drug eluting stents which suppress the normal endothelial function .
What is the realistic view ?
A stent should be used cautiously and judiciously in coronary plaques with high risk features .Here a stent in all probability converts a vulnerable plaque into a relatively stable plaque
When stenting is done indiscriminately( without application of mind ) in stable non flow limiting lesions stability is replaced with vulnerability.
Is it not curious to know any angina in a patient who had PCI for chronic stable angina is labeled as unstable angina.
Following are typical clinical scenarios where stents could carry a vulnerability tag .
- Poorly deployed stents
- Properly deployed (but unnecessarily deployed especially in chronic stable angina )
- All Bifurcation stents
- Distal left main stents
- Stents with plaque prolapse
- Finally and most importantly all drug eluting stents are considered vulnerable ! (That’s why our patients has to live at the mercy of dual platelet blockers , life long. Of course , there is no life time warranty that drugs do their job properly)
And now . . . you answer my question !
Can stenting convert a stable plaque into vulnerable plaque ?
- If “yes’ is your answer your patients are in safe hands .
- If ” No” is your answer , you are fit to become a leading interventional cardiologist !