PCI in the patient with in stent restenosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Laura Nasrallah, M.D.;
Synonyms and Keywords: ISR
Overview
In-stent restenosis (ISR) is the most frequent late complication of stent implantation and occurs when there is a reoccurrence of stenosis in a lesion that was previously treated with a stent. In stent restenosis results from exaggerated neointimal formation. The lesion is primarily composed of smooth muscle cells and extracellular matrix. Intravascular ultrasound studies demonstrate that in stent restenosis is not due to extrinsic compression of the stent by scar tissue (i.e. there is not compression of the stent).
Epidemiology and Demographics
Although ISR has traditionally occurred in 30-40% of treated lesions, its incidence has been dramatically reduced by the development of drug-eluting stents.
Risk Factors
Patient-based Risk Factors
Lesion-based Risk Factors
- Longer lesion length
- Smaller caliber vessel
- Greater plaque burden
- Ostial lesion location
- The presence of a chronic total occlusion
- Left anterior descending coronary artery location
- Saphenous vein graft lesion
Procedure Based Risk Factors
- A residual stenosis >30%
- A residual pressure gradient > 20 mmHg
- An increased number, overlap, and length of stents
Treatment
The major goal of treating in-stent restenosis is to minimize the chance of recurrent restenosis. If a bare metal stent develops ISR, then a drug eluting stent should be placed. If ISR develops in a drug eluting stent, there is no data to suggest that a different type of drug eluting stent will prevent a recurrence (e.g. switching from sirolimus to paclitaxel). While use of a cutting balloon may improve acute angiographic results, there is no data to suggests that the use of a cutting balloon reduces the risk of a recurrence. Radiation treatment or brachytherapy was used in the past to treat ISR, but this procedure was associated with a higher rate of late stent thrombosis, and had fallen out of favor.
2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[1]
Restenosis (DO NOT EDIT)[1]
| Class I |
| "1. Patients who develop clinical restenosis after balloon angioplasty should be treated with bare metal stent (BMS) or drug eluting stent (DES) if anatomic factors are appropriate and if the patient is able to comply with and tolerate dual antiplatelet therapy (DAPT).[2] (Level of Evidence: B)" |
| "2. Patients who develop clinical restenosis after bare metal stent (BMS) should be treated with drug eluting stent (DES) if anatomic factors are appropriate and the patient is able to comply with and tolerate dual antiplatelet therapy (DAPT).[3][4][5](Level of Evidence: A)" |
| Class IIa |
| "1. IVUS is reasonable to determine the mechanism of stent restenosis.[6] (Level of Evidence: C)" |
| Class IIb |
| "1. Patients who develop clinical restenosis after drug eluting stent (DES) may be considered for repeat PCI with balloon angioplasty, bare metal stent (BMS), or drug eluting stent (DES) containing the same drug or an alternative antiproliferative drug if anatomic factors are appropriate and the patient is able to comply with and tolerate dual antiplatelet therapy (DAPT).[6] (Level of Evidence: C)" |
References
- ↑ 1.0 1.1 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Retrieved 2011-12-08. Text "PDF" ignored (help); Unknown parameter
|month=ignored (help) - ↑ Erbel R, Haude M, Höpp HW, Franzen D, Rupprecht HJ, Heublein B, Fischer K, de Jaegere P, Serruys P, Rutsch W, Probst P (1998). "Coronary-artery stenting compared with balloon angioplasty for restenosis after initial balloon angioplasty. Restenosis Stent Study Group". The New England Journal of Medicine. 339 (23): 1672–8. doi:10.1056/NEJM199812033392304. PMID 9834304. Retrieved 2011-12-16. Unknown parameter
|month=ignored (help) - ↑ Holmes DR, Teirstein P, Satler L, Sketch M, O'Malley J, Popma JJ, Kuntz RE, Fitzgerald PJ, Wang H, Caramanica E, Cohen SA (2006). "Sirolimus-eluting stents vs vascular brachytherapy for in-stent restenosis within bare-metal stents: the SISR randomized trial". JAMA : the Journal of the American Medical Association. 295 (11): 1264–73. doi:10.1001/jama.295.11.1264. PMID 16531619. Retrieved 2011-12-16. Unknown parameter
|month=ignored (help) - ↑ Dibra A, Kastrati A, Alfonso F, Seyfarth M, Pérez-Vizcayno MJ, Mehilli J, Schömig A (2007). "Effectiveness of drug-eluting stents in patients with bare-metal in-stent restenosis: meta-analysis of randomized trials". Journal of the American College of Cardiology. 49 (5): 616–23. doi:10.1016/j.jacc.2006.10.049. PMID 17276188. Retrieved 2011-12-16. Unknown parameter
|month=ignored (help) - ↑ Kastrati A, Mehilli J, von Beckerath N, Dibra A, Hausleiter J, Pache J, Schühlen H, Schmitt C, Dirschinger J, Schömig A (2005). "Sirolimus-eluting stent or paclitaxel-eluting stent vs balloon angioplasty for prevention of recurrences in patients with coronary in-stent restenosis: a randomized controlled trial". JAMA : the Journal of the American Medical Association. 293 (2): 165–71. doi:10.1001/jama.293.2.165. PMID 15644543. Retrieved 2011-12-16. Unknown parameter
|month=ignored (help) - ↑ 6.0 6.1 Dangas GD, Claessen BE, Caixeta A, Sanidas EA, Mintz GS, Mehran R (2010). "In-stent restenosis in the drug-eluting stent era". Journal of the American College of Cardiology. 56 (23): 1897–907. doi:10.1016/j.jacc.2010.07.028. PMID 21109112. Retrieved 2011-12-16. Unknown parameter
|month=ignored (help)