By Dr. Praveen Chandra, Padma Shri, Chairman, Interventional Cardiology, Medanta – The Medicity, Gurugram

A patient recently arrived in my consulting room holding a coronary angiogram report from another city, a single line circled in pen: seventy percent blockage. He had already, in his mind, scheduled the procedure. What he had not yet heard, and what modern cardiology increasingly insists upon before any decision is made, is that a percentage on an angiogram report is the beginning of a clinical conversation, not its conclusion.

This is, I have come to believe, one of the more important shifts in my own field over the past decade. Interventional cardiology has moved decisively away from treating what a blockage looks like on an X-ray image toward understanding what it actually does to blood flow and to the patient experiencing it. That distinction, between anatomy and physiology, between a picture and a functional reality, now sits at the centre of every serious decision about whether a stent is necessary, optional, or altogether unwarranted.

The Core Question: Does a Visual Blockage Always Demand a Stent?

For much of the history of interventional cardiology, treatment decisions were guided primarily by what the angiogram showed: a narrowing that appeared to reduce a vessel’s diameter by seventy percent or more was often treated as self-evidently significant, and a stent followed as a matter of course. Landmark research over the past two decades has complicated this picture considerably, and the complication has been, on the whole, a welcome one for patients.

The COURAGE trial, and more recently the large-scale ISCHEMIA trial involving over five thousand patients with stable coronary disease and demonstrable ischemia, found that adding stenting to optimal medical therapy did not reduce the rate of death or heart attack compared with optimal medical therapy alone, even among patients with moderate to severe ischemia on stress testing. Stenting did meaningfully improve angina symptoms, with a notably higher proportion of patients becoming symptom-free within a year compared with medication alone, but the hoped-for reduction in hard outcomes such as death and myocardial infarction simply did not materialise for this stable population.

The clinical implication is precise rather than sweeping. For a patient with stable coronary artery disease, minimal or no anginal symptoms, and a reasonable quality of life, current evidence does not support routine stenting purely on the basis of an anatomical blockage. Optimal medical therapy, encompassing statins, antiplatelet agents, blood pressure control, and disciplined lifestyle modification, remains the appropriate first-line strategy, with revascularisation reserved for patients whose symptoms persist or worsen despite this therapy, or whose anatomy carries risk that medication cannot address.

When Is a Stent Strictly Necessary?

Not every clinical scenario carries this same nuance, and it would be a disservice to patients to suggest otherwise. Some situations leave no room for deliberation.

Acute emergencies. In an ST-elevation myocardial infarction, a complete blockage of a coronary artery causing an active heart attack, and in unstable angina with high-risk features, immediate angioplasty is unambiguously life-saving. Here, the physiological question has already answered itself: blood flow has stopped, heart muscle is dying by the minute, and mechanical restoration of flow through primary angioplasty is the standard of care worldwide, non-negotiable and time-critical.

Left main coronary disease. A significant blockage in the left main artery, which supplies the majority of the heart’s blood flow, is treated with urgency regardless of symptom severity, given the scale of myocardium placed at risk by this single vessel.

Complex anatomical disease. Multivessel disease, bifurcation lesions where a blockage sits at the junction of two vessels, and chronic total occlusions, arteries blocked completely for three months or longer, each carry distinct technical and clinical considerations that typically favour intervention, particularly when accompanied by symptoms or objective evidence of ischemia.

Between these two poles, the true emergency that permits no deliberation, and the stable, minimally symptomatic patient for whom medication is appropriate, lies the far more common and more nuanced middle ground: the patient with an intermediate blockage and some symptoms, for whom the decision genuinely depends on precise, physiological evidence rather than the angiogram’s visual impression alone.

Precision Diagnostics: The Tools That Prevent Unnecessary Stenting

This is where contemporary interventional cardiology has made its most meaningful advances, not in the stents themselves, but in the diagnostic precision that determines whether a stent is warranted at all.

Fractional Flow Reserve and iFR. Fractional flow reserve, measured by passing a pressure wire across a blockage during catheterisation, quantifies precisely how much a narrowing is limiting blood flow, rather than relying on how the blockage merely appears on an angiogram. The FAME 2 trial demonstrated this value directly: among patients with stable coronary disease and a functionally significant blockage confirmed by FFR, adding PCI to medical therapy meaningfully reduced the composite of death, heart attack, or urgent revascularisation over long-term follow-up, a benefit driven primarily by a substantial reduction in urgent procedures later. Equally telling, patients found on FFR testing not to have a functionally significant blockage did well on medical therapy alone, confirming that the pressure-wire measurement, not the angiogram’s visual estimate, is what should ultimately guide the decision to stent. The related iFR technique offers a comparable physiological assessment without requiring the medication used to induce maximal blood flow during FFR, adding convenience without sacrificing accuracy.

Intravascular imaging: IVUS and OCT. Once a decision to stent has been made, a second question follows immediately: has the stent been placed correctly? Intravascular ultrasound and optical coherence tomography provide a high-resolution, from-the-inside view of the vessel wall that angiography, a two-dimensional shadow image, simply cannot offer. The ULTIMATE trial, following patients for three years, found that IVUS-guided stent implantation significantly lowered the risk of target vessel failure compared with angiography guidance alone, a benefit that grew more pronounced over time and was strongest among patients whose procedures met IVUS-defined criteria for an optimal result. More recent large-scale trials in complex lesions and acute coronary syndromes have reinforced this finding consistently. In practical terms, this technology allows an interventional cardiologist to confirm precise stent sizing, complete lesion coverage, and full stent apposition against the vessel wall, materially reducing the risk of the two complications that most concern any cardiologist placing a stent: in-stent restenosis and stent thrombosis.

Managing heavily calcified disease. Severely calcified coronary arteries, common in older patients and those with long-standing diabetes or kidney disease, pose a distinct technical challenge, since a stent cannot expand properly against a vessel wall that is unyielding. Rotational atherectomy, which uses a high-speed diamond-tipped burr to modify calcified plaque, and intravascular lithotripsy, which uses targeted acoustic energy to fracture calcium deposits, have become essential tools for preparing these lesions safely, allowing a stent to be deployed with the full, even expansion required for a durable, long-term result.

Complex, High-Risk, and Indicated Patients: The CHIP Frontier

A distinct and growing category of patients deserves particular mention: those with complex coronary anatomy, reduced heart pump function, and significant coexisting conditions such as diabetes, kidney disease, or prior bypass surgery, who have often been told, elsewhere, that they are not candidates for either open-heart surgery or conventional angioplasty. In contemporary interventional cardiology, this population is referred to as complex, high-risk, and indicated patients, or CHIP, and treating them safely represents one of the more technically demanding frontiers in the field.

The defining innovation enabling CHIP intervention has been percutaneous mechanical circulatory support, most notably the Impella device, a catheter-based micro-axial pump that temporarily assists the heart’s pumping function during a procedure, allowing an interventional cardiologist to work on complex, high-risk anatomy, left main disease, extensively calcified vessels, or a patient’s last remaining functional artery, without the haemodynamic collapse that might otherwise occur. In more extreme circumstances, venoarterial ECMO can provide even more comprehensive circulatory and respiratory support during the highest-risk procedures.

In the interest of the clinical transparency this article promised at the outset, it is worth noting candidly that the evidence base for routine prophylactic Impella use continues to evolve. The CHIP-BCIS3 trial, a large randomised study presented in 2026, found that routine Impella support during complex, high-risk PCI did not reduce major adverse cardiac events compared with standard care in this population, and hemodynamic substudy data suggested it may, in certain cases, be associated with greater periprocedural myocardial injury. This finding does not diminish the genuine, well-documented value of mechanical circulatory support in carefully selected patients, particularly those with severely reduced heart function undergoing the most extensive revascularisation, but it does reinforce an important principle that should guide any CHIP programme: these tools are decided upon by an experienced multidisciplinary heart team on a case-by-case basis, not applied as a routine default, and the evidence guiding their use is continually reassessed as new data emerges.

Why Choose India and Dr. Praveen Chandra for Complex Angioplasty

For patients evaluating where to pursue treatment for a borderline blockage, a multivessel disease diagnosis, or a CHIP-level intervention previously declined elsewhere, the quality of the outcome depends substantially on the depth of experience and diagnostic discipline behind the recommendation. Dr. Praveen Chandra, a Padma Shri awardee and Chairman of Interventional Cardiology at Medanta – The Medicity, Gurugram, has built a practice around exactly this discipline, with decades of experience in complex angioplasty, structural heart interventions, and high-risk percutaneous revascularisation, working within a multidisciplinary heart team model in which decisions are made collectively rather than unilaterally.

Medanta’s infrastructure supports this approach directly. The hospital’s hybrid operating suites and dedicated, high-end cardiac catheterisation laboratories bring imaging, physiological assessment, and interventional capability into a single environment, while dedicated cardiac intensive care units provide continuous monitoring for complex and CHIP-level cases. Medanta holds accreditation from the Joint Commission International, alongside national NABH and NABL accreditation, reflecting adherence to internationally benchmarked standards of patient safety and procedural quality.

For international patients, this pathway typically begins well before travel is arranged. Recent angiogram imaging, whether on a CD, DICOM file, or digital report, can be submitted for a remote tele-consultation second opinion, allowing an initial assessment of whether medical therapy, straightforward angioplasty, or a more complex CHIP-level intervention is genuinely warranted, before a patient commits to travel. From there, Medanta’s international patient services coordinate the practical elements of the visit, transparent cost estimates, medical visa documentation support, airport transfers, multilingual patient coordinators, and structured post-procedure follow-up once a patient has returned home, so that a second opinion sought from abroad translates smoothly into coordinated, continuous care.

Frequently Asked Questions

Can a 70 percent blockage be treated with medicine alone, without a stent?

In many cases, yes, particularly if the patient has stable symptoms, a reasonable quality of life, and the blockage is not confirmed as functionally significant on physiological testing such as FFR. Major trials including ISCHEMIA and FAME 2 have shown that optimal medical therapy alone can be an entirely appropriate strategy for many patients with stable coronary disease, with revascularisation reserved for those whose symptoms persist despite medication or whose testing confirms a flow-limiting blockage. This decision should always be made individually, following a thorough evaluation rather than the angiogram percentage in isolation.

How durable are modern drug-eluting stents?

Contemporary drug-eluting stents have demonstrated strong long-term durability in large trials, with low rates of target vessel failure and stent thrombosis when implantation is optimised, particularly when guided by intravascular imaging such as IVUS or OCT. Most patients experience excellent, lasting results, though ongoing risk factor control, including blood pressure, cholesterol, and blood sugar management, alongside prescribed antiplatelet therapy, remains essential to preserving that durability over the years that follow.

Is angioplasty safe for elderly patients with multiple comorbidities?

Angioplasty can be performed safely in carefully selected elderly patients with multiple comorbidities, though the decision requires more individualised assessment than in younger, healthier patients. For complex cases involving reduced heart function or extensive coronary disease, mechanical circulatory support and a multidisciplinary heart team evaluation help manage the additional risk. The right approach depends on overall health, frailty, kidney function, and the specific anatomy involved, and is best determined through a detailed in-person or tele-consultation evaluation rather than age alone.

How soon can international patients fly back after an elective angioplasty?

Most patients undergoing an uncomplicated elective angioplasty can expect a hospital stay of one to two days, with air travel generally considered safe within a few days to a week afterward, depending on the individual’s recovery and the treating cardiologist’s assessment. Patients undergoing more complex, CHIP-level procedures typically require a longer observation period before travel is cleared. Precise timing should always be confirmed directly with the treating team based on the specific procedure performed.