DISCUSSION
CAD, two‐thirds of lesions, cardiogenic shock
ADVERSE EVENTS, EVENT, CAD, CARDIOGENIC SHOCK
We evaluated the procedural success and 12‐month safety and efficacy of the ultra‐long DES implantation in treating diffuse long CAD in all‐comer patients and compared outcomes with those of multiple overlapping conventional DES implantation. Several findings emerged from our analyses. First, 26% of the patients had a lesion longer than 40 mm and thus were required to be treated with <40 mm multiple DESs. Second, stent deliverability—as regards stent delivery failure at the first attempt and the use of guide‐extension catheter or anchor balloon technique—did not differ between both groups. Third, approximately two‐thirds of lesions could be treated with one ultra‐long DES. Fourth, using the ultra‐long DES could reduce the contrast volume. Finally, device‐related adverse events during the 1‐year follow‐up were few, without statistical differences, regardless of using an ultra‐long DES.Diffuse CAD is a significant prognostic factor after PCI.However, there is potential concern about using the ultra‐long DES. First is a size discrepancy between the proximal and distal RVD. The current ultra‐long DES has the same diameter along the stent length; therefore, appropriate stent‐sizing could be problematic.In this study, we could not find differences in device‐related outcomes between both groups after adjustment. Moreover, there is a relative lack of clinical data supporting whether the longer DES is better than the overlapping DES because extremely long lesions are often under‐represented in clinical trials, and there are no direct comparison trials. However, in the era of newer‐generation DESs, overlapping DES is considered comparable with single DES, with conflicting results.In previous studies based on a single‐arm registry, the 48 mm Xience Xpedition showed good safety and efficacy for up to 2 years.Our study revealed low event rates, and there are several reasons. First, patients with cardiogenic shock at presentation or who died during the index hospitalization were excluded; Second, periprocedural MI was not included; Third, routine follow‐up coronary angiography was not mandatory; Finally, a significant proportion of patients underwent PCI using the transradial access and IVUS guidance.Our study has several limitations. First, it was not a randomized controlled trial; therefore, it has inherent potential bias. After propensity score‐matching, POCO became significant in the conventional DES group. This may reflect that more fragile patients with a more hostile coronary anatomy, where the ultra‐long DES could not cross the lesion, could have been included in the conventional DES group despite a statistical adjustment. Second, the stent choice was at the operator's discretion. The experienced operator might not choose the ultra‐long DES in extremely hostile lesion because the operator already knows that the ultra‐long DES cannot be easily delivered into such a lesion. The higher TLR rate in the conventional DES group among the overall population could be related to lesion characteristics rather than stent selection. Third, statistical power could be low owing to the small sample size and low event rates. Fourth, various stent platforms were used in the conventional DES group. Thus, a direct comparison of stent types was not possible. Finally, a 1‐year follow‐up might be too short; therefore, a longer‐term follow‐up should be considered for a more robust conclusion.