Seeing the Unseen: Enhanced Stent Visualization Revealing Hidden Coronary Stent Complications

Accurate evaluation of stent implantation during percutaneous coronary intervention (PCI) is essential to reduce both early and late adverse events, including stent thrombosis and in-stent restenosis. Although conventional coronary angiography remains the standard imaging modality, its spatial resolution is often insufficient to detect subtle mechanical abnormalities of implanted stents. Enhanced stent visualization (ESV) is an X-ray-based post-processing technique that enhances delineation of stent struts using routine fluoroscopic images, without requiring additional contrast administration or intracoronary instrumentation. We describe a case series of five patients undergoing complex PCI in whom ESV proved crucial for the detection of mechanical complications that were not readily evident on angiography alone. The procedures involved challenging anatomical and clinical settings, including left main coronary artery treatment, bifurcation lesions, multivessel coronary disease, and acute coronary syndromes. In each case, ESV offered incremental diagnostic insight, enabling prompt identification of complications. These findings directly influenced procedural strategy and facilitated appropriate bailout interventions. This case series underscores the potential clinical utility of ESV as an adjunctive imaging tool to standard angiography and intravascular imaging techniques. Given its simplicity, broad accessibility, and negligible effect on procedure duration, ESV represents a feasible option during PCI. In selected complex interventions, its use may enhance mechanical optimization and procedural safety. Further large-scale prospective investigations are needed to corroborate the implementation of ESV in clinical practice.