The treatment of long and calcified lesions may be complicated by problems with device delivery. In this setting, the selection of the optimal guiding catheter is of even more importance than usual. Excellent catheter support often is required. As the lesion length increases, the placement of longer devices is required, and these longer devices, particularly longer stents, are increasingly rigid and difficult to place. In addition, if the lesion is calcified, then resistance to passage of the stent also is increased. In this setting, direct stenting usually is not a preferred approach. Indeed, in trials, lesion calcification often is a contraindication to attempts at direct stenting. Boulmier et al. (11) evaluated direct stenting with balloon predilatation in lesions requiring long stents. In a prospective multicenter registry of 128 patients, the mean lesion length was 20.7 ± 5.4 mm, and the mean stent length was 21.4 ± 3.8 mm. With multivariate analysis, the presence of calcium was strongly associated with failure of direct stenting (p = 0.004). In another larger single-center series of 1,000 lesions, Martininez-Luengas (12) also found that calcification was associated with a reduced initial success rate. These and other series have resulted in the exclusion of calcified lesions from many randomized trials. If the stent cannot be delivered, then the issue of withdrawing the stent back into the guiding catheter often is encountered, with the potential of damage to the stent or even stent embolization. If the stent cannot be delivered and instead is to be withdrawn into the guiding catheter, then it is of utmost importance to align the latter in the most coaxial position possible. For these reasons, in the treatment of long and calcified lesions, predilatation is important.

Although the concept of predilatation is straightforward, some important considerations must be addressed. The operator must identify the limits of the arterial segment that was treated with predilatation so that, when the stent is implanted, it adequately covers the entire dilated length. In general, a stent 2 to 4 mm longer on each end of the dilated diseased segment is the goal. This is important
to avoid “geographic miss” when using DES. It also was important when vascular brachytherapy was used more widely. The selection of the proper size of the predilatation balloon also is important. The balloon should be of adequate size so that subsequent attempts to deliver the stent are more apt to be successful; typically, we select a balloon approximately 0.5 mm smaller than the final intended stent size. After predilatation, when the balloon is “winged” with a larger profile, it is often helpful to try to redeliver that same balloon to the target area. If that subsequent attempt is difficult, then a larger predilatation balloon should be selected and used.