Vascular stents and atherosclerosis.

atherosclerotic vascular disease. This excitement, however, sometimes produces expectations for the future that leap beyond the necessary tedium of scientific investigation. One of my European colleagues recently quipped that investigators from the United States, in describing their latest endeavors, often use the words,, "I'm excited." Well, we are excited about the possibility of expanding the capabilities of cardiologists to work safely and effectively inside the coronary and other arteries. After all, Gruentzig envisioned balloon angioplasty as only the beginning of interventional cardiovascular medicine. The editorial by Schatz in this issue, "A View of Vascular Stents,"1 expresses sufficient excitement to cause me to ask several questions. Is there a problem? Can the proposed approach address the problem (potential efficacy)? Is the treatment worse than the disease (safety)? If the weapons devised work in the ideal (experimental) setting, can they be made sufficiently foolproof to be used in the clinical setting (value)? First, is there a problem? Acute closure of the coronary artery being dilated results in the need for emergency bypass surgery in 3-5% of patients and myocardial infarction in approximately half that number. Acute closure results largely from plaque disruption and dissection, with spasm and thrombosis being secondary events. As more patients with multivessel and diffuse disease are undergoing angioplasty, the problem of acute closure increases. A solution to acute closure would make percutaneous transluminal coronary angioplasty (PTCA) safer for those who have it and would significantly expand