Advances in
stent technology and the design of endovascular devices with thinner struts, anti-inflammatory and antithrombotic
polymers, and better drug kinetics have enhanced the safety and efficacy of the second-generation
drug-eluting stents and broadened their use in the
therapy of high-risk patients and complex anatomies. However, despite these developments, in-
stent restenosis and
stent thrombosis remain the Achilles' heel of
percutaneous coronary intervention, with their cumulative incidence reaching up to 10% at 5 years following
percutaneous coronary intervention. The treatment of
stent failure poses challenges and is associated with a worse prognosis than conventional
percutaneous coronary intervention. Several studies have recently highlighted the value of intravascular imaging in identifying causes of
stent failure, underscored its role in treatment planning, and registries have shown that its use may be associated with better clinical outcomes. The present review aims to summarize the evidence in the field; it discusses the value of intravascular imaging in identifying the mechanisms of in-
stent restenosis and
stent thrombosis in assessing the morphological characteristics of
neointima tissue that appears to determine long-term outcomes in evaluating procedural results, and presents the findings of studies supporting its value in guiding
therapy in
stent failure.