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The major drawback of coronary stenting is the need to vigorous anticoagulation. This study was to prospectively test the safety and efficacy of intravascular ultrasound (IVUS) guided optimized stent placement without post procedural systemic anticoagulation. IVUS was intended in 105 pats with Palmaz Schatz stent placement after balloon angioplasty (PTCA) complicated by progressive dissection (76 pats single stent; 28 multiple stents). After acceptable angiographic result. IVUS (2.9F; 30 MHz caths) was successfully performed in 104/105 (99%) pats. IVUS criteria for optimal stent placement were either a in-stent minimal lumen area (MLA)≥90% of the reference MLA and/or a in-stent MLA of≥8.0mm2and a complete coverage of the dissection by stent. In a total of 14/104 (14%) these IVUS criteria were primarily reached. In 90/104 (86%) balloon expansion (increased balloon seize; short balloon; high pressure) was repeatedly performed. In 46 pats of this group IVUS criteria were fulfilled. The additional acute lumen gain from 1st to final IVUS trip was 2.3±1.2 mm2(37%). Thereby in a total of 60/1 04 (57%) pats IVUS criteria could be reached and were confirmed by the final IVUS trip. All 60 pats received Heparin for 24h and no oral anticoagulation beside aspirin (100mg tid) and ticlopidin (250mg tid). During the post stent observation period of 4 weeks no deaths, no subsequent myocardial infarction and no stent occlusion occurred. Either bleeding or vascular complications were seen in 1 pat, respectively. In the 54 pats requiring coumadin therapy, there were 1 subacute stent occlusion, 1 death, 3 bleeding and 6 vascular complications. Thus, IVUS guided optimized coronary Palmaz Schatz stent placement and expansion without post procedural systemic anticoagulation is a safe and effective therapeutic regimen.