PCI complications: restenosis: Difference between revisions

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Revision as of 13:31, 4 July 2022

Editors-In-Chief: Alexandra Almonacid M.D.; Jeffrey J. Popma M.D. Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[1]

Restenosis

Overview

Classification

The following are the one of the classifications:^[1]

Pattern I: Focal (≤ 10 mm in length) lesions
- Ia : Restenosis within the stent
- Ib : Restenosis at the edge of the stent
- Ic : Restenosis at the articulation or gap
- Id : Restenosis multifocal
Pattern II: ISR >10 mm within the stent
Pattern III: Includes ISR > 10 mm extending outside the stent
Pattern IV: ISR totally occluded

The need for recurrent target lesion revascularization (TLR) increased with increasing ISR class, increasing from 19%, 35%, 50%, to 83% in classes I to IV, respectively (P <0.001)^[1].

Pathophysiology

Restenosis can occur in the implanted stent after performing PCI.^[2]
The main mechanism causing restenosis after stent implication is neointimal hyperplasia^[1]^[3]^[4]^[5]
The pathophysiology of restenosis can be anticipated based on the time period that restenosis occurs.^[2]
- Early stent thrombosis is usually due to residual target-lesion thrombus, stent failure, or nonadherence to dual antiplatelet therapy.
- Late stent thrombosis is usually associated with inadequate neointimal coverage or incomplete healing.
Restenosis after drug eluting stent implantation is generally more focal than following bare metal stent placement^[6]^[7], and, with the sirolimus eluting stent, more is commonly at the margin of the stent due to balloon injury that is not covered with stent^[6]^[7]^[8].

Epidemiology and Demographics

ISR is found in 5% to 10% of patients undergoing PCI.^[9]^[10]

Causes

Risk of ISR is lowered after presentation of new generations stents such as DES compared to BMS and first-generation DES.^[11]^[12]
Factors such as stent type, chosen procedure, and patient-related factors are critical in the pathophysiology of stent thrombosis or restenosis.^[9]^[13]

Natural History, Complications and Prognosis

Diagnosis

It is necessary to evaluate the underlying cause of stent thrombosis with intracoronary imaging (IVUS and OCT) in order to plan the proper treatment.^[9]^[14]
In the setting of in-stent restenosis (ISR) after bare metal stent (BMS) implantation, the risk of recurrence can be predicted by the pattern of restenosis.

2021 ACA Guidline Recommendations

Class 1 Recommendation, Level of Evidence: A^[2]
If another PCI is planned for a patient with clinical in-stent restenosis (ISR), drug eluting stent (DES) is recommended with goal of outcome improvement (if anatomic factors and dual antiplatelet therapy (DAPT) compliance are considered).

Class 2a Recommendation, Level of Evidence: C-EO ^[2]
If a patient with recurrent symptomatic diffuse in-stent restenosis (ISR) has a revascularization indication, planning CABG is preferred over repeat PCI to lower recurrent events.

Class 2b Recommendation, Level of Evidence: B-NR ^[2]
In a patient with recurrent in-stent restenosis (ISR), brachytherapy could be helpful to improve symptoms

References

↑ ^1.0 ^1.1 ^1.2 Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF; et al. (1999). "Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome". Circulation. 100 (18): 1872–8. PMID 10545431.
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check |pmid= value (help).
↑ Goto K, Zhao Z, Matsumura M, Dohi T, Kobayashi N, Kirtane AJ; et al. (2015). "Mechanisms and Patterns of Intravascular Ultrasound In-Stent Restenosis Among Bare Metal Stents and First- and Second-Generation Drug-Eluting Stents". Am J Cardiol. 116 (9): 1351–7. doi:10.1016/j.amjcard.2015.07.058. PMID 26341188.
↑ Kang SJ, Mintz GS, Park DW, Lee SW, Kim YH, Whan Lee C; et al. (2011). "Mechanisms of in-stent restenosis after drug-eluting stent implantation: intravascular ultrasound analysis". Circ Cardiovasc Interv. 4 (1): 9–14. doi:10.1161/CIRCINTERVENTIONS.110.940320. PMID 21266707.
↑ Farb A, Sangiorgi G, Carter AJ, Walley VM, Edwards WD, Schwartz RS; et al. (1999). "Pathology of acute and chronic coronary stenting in humans". Circulation. 99 (1): 44–52. doi:10.1161/01.cir.99.1.44. PMID 9884378.
↑ ^6.0 ^6.1 Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M; et al. (2004). "Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries". Circulation. 110 (25): 3773–80. doi:10.1161/01.CIR.0000150331.14687.4B. PMID 15596568.
↑ ^7.0 ^7.1 Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M; et al. (2003). "Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation". Circulation. 107 (17): 2178–80. doi:10.1161/01.CIR.0000070592.04766.36. PMID 12719283.
↑ Lemos PA, Saia F, Ligthart JM, Arampatzis CA, Sianos G, Tanabe K; et al. (2003). "Coronary restenosis after sirolimus-eluting stent implantation: morphological description and mechanistic analysis from a consecutive series of cases". Circulation. 108 (3): 257–60. doi:10.1161/01.CIR.0000083366.33686.11. PMID 12860901.
↑ ^9.0 ^9.1 ^9.2 Dangas GD, Claessen BE, Caixeta A, Sanidas EA, Mintz GS, Mehran R (2010). "In-stent restenosis in the drug-eluting stent era". J Am Coll Cardiol. 56 (23): 1897–907. doi:10.1016/j.jacc.2010.07.028. PMID 21109112.
↑ Alfonso F, Byrne RA, Rivero F, Kastrati A (2014). "Current treatment of in-stent restenosis". J Am Coll Cardiol. 63 (24): 2659–73. doi:10.1016/j.jacc.2014.02.545. PMID 24632282.
↑ Tada T, Byrne RA, Simunovic I, King LA, Cassese S, Joner M; et al. (2013). "Risk of stent thrombosis among bare-metal stents, first-generation drug-eluting stents, and second-generation drug-eluting stents: results from a registry of 18,334 patients". JACC Cardiovasc Interv. 6 (12): 1267–74. doi:10.1016/j.jcin.2013.06.015. PMID 24355117.
↑ Gada H, Kirtane AJ, Newman W, Sanz M, Hermiller JB, Mahaffey KW; et al. (2013). "5-year results of a randomized comparison of XIENCE V everolimus-eluting and TAXUS paclitaxel-eluting stents: final results from the SPIRIT III trial (clinical evaluation of the XIENCE V everolimus eluting coronary stent system in the treatment of patients with de novo native coronary artery lesions)". JACC Cardiovasc Interv. 6 (12): 1263–6. doi:10.1016/j.jcin.2013.07.009. PMID 24239202.
↑ Holmes DR, Kereiakes DJ, Garg S, Serruys PW, Dehmer GJ, Ellis SG; et al. (2010). "Stent thrombosis". J Am Coll Cardiol. 56 (17): 1357–65. doi:10.1016/j.jacc.2010.07.016. PMID 20946992.
↑ Fujii K, Mintz GS, Kobayashi Y, Carlier SG, Takebayashi H, Yasuda T; et al. (2004). "Contribution of stent underexpansion to recurrence after sirolimus-eluting stent implantation for in-stent restenosis". Circulation. 109 (9): 1085–8. doi:10.1161/01.CIR.0000121327.67756.19. PMID 14993129.

Template:WH Template:WS

Template:WikiDoc Sources

[pmid10545431-1] 1.0 ^1.1 ^1.2 Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF; et al. (1999). "Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome". Circulation. 100 (18): 1872–8. PMID 10545431.

[pmid34895950-2] 2.0 ^2.1 ^2.2 ^2.3 ^2.4 Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check |pmid= value (help).

[pmid26341188-3] Goto K, Zhao Z, Matsumura M, Dohi T, Kobayashi N, Kirtane AJ; et al. (2015). "Mechanisms and Patterns of Intravascular Ultrasound In-Stent Restenosis Among Bare Metal Stents and First- and Second-Generation Drug-Eluting Stents". Am J Cardiol. 116 (9): 1351–7. doi:10.1016/j.amjcard.2015.07.058. PMID 26341188.

[pmid21266707-4] Kang SJ, Mintz GS, Park DW, Lee SW, Kim YH, Whan Lee C; et al. (2011). "Mechanisms of in-stent restenosis after drug-eluting stent implantation: intravascular ultrasound analysis". Circ Cardiovasc Interv. 4 (1): 9–14. doi:10.1161/CIRCINTERVENTIONS.110.940320. PMID 21266707.

[pmid9884378-5] Farb A, Sangiorgi G, Carter AJ, Walley VM, Edwards WD, Schwartz RS; et al. (1999). "Pathology of acute and chronic coronary stenting in humans". Circulation. 99 (1): 44–52. doi:10.1161/01.cir.99.1.44. PMID 9884378.

[pmid15596568-6] 6.0 ^6.1 Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M; et al. (2004). "Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries". Circulation. 110 (25): 3773–80. doi:10.1161/01.CIR.0000150331.14687.4B. PMID 15596568.

[pmid12719283-7] 7.0 ^7.1 Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M; et al. (2003). "Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation". Circulation. 107 (17): 2178–80. doi:10.1161/01.CIR.0000070592.04766.36. PMID 12719283.

[pmid12860901-8] Lemos PA, Saia F, Ligthart JM, Arampatzis CA, Sianos G, Tanabe K; et al. (2003). "Coronary restenosis after sirolimus-eluting stent implantation: morphological description and mechanistic analysis from a consecutive series of cases". Circulation. 108 (3): 257–60. doi:10.1161/01.CIR.0000083366.33686.11. PMID 12860901.

[pmid21109112-9] 9.0 ^9.1 ^9.2 Dangas GD, Claessen BE, Caixeta A, Sanidas EA, Mintz GS, Mehran R (2010). "In-stent restenosis in the drug-eluting stent era". J Am Coll Cardiol. 56 (23): 1897–907. doi:10.1016/j.jacc.2010.07.028. PMID 21109112.

[pmid24632282-10] Alfonso F, Byrne RA, Rivero F, Kastrati A (2014). "Current treatment of in-stent restenosis". J Am Coll Cardiol. 63 (24): 2659–73. doi:10.1016/j.jacc.2014.02.545. PMID 24632282.

[pmid24355117-11] Tada T, Byrne RA, Simunovic I, King LA, Cassese S, Joner M; et al. (2013). "Risk of stent thrombosis among bare-metal stents, first-generation drug-eluting stents, and second-generation drug-eluting stents: results from a registry of 18,334 patients". JACC Cardiovasc Interv. 6 (12): 1267–74. doi:10.1016/j.jcin.2013.06.015. PMID 24355117.

[pmid24239202-12] Gada H, Kirtane AJ, Newman W, Sanz M, Hermiller JB, Mahaffey KW; et al. (2013). "5-year results of a randomized comparison of XIENCE V everolimus-eluting and TAXUS paclitaxel-eluting stents: final results from the SPIRIT III trial (clinical evaluation of the XIENCE V everolimus eluting coronary stent system in the treatment of patients with de novo native coronary artery lesions)". JACC Cardiovasc Interv. 6 (12): 1263–6. doi:10.1016/j.jcin.2013.07.009. PMID 24239202.

[pmid20946992-13] Holmes DR, Kereiakes DJ, Garg S, Serruys PW, Dehmer GJ, Ellis SG; et al. (2010). "Stent thrombosis". J Am Coll Cardiol. 56 (17): 1357–65. doi:10.1016/j.jacc.2010.07.016. PMID 20946992.

[pmid14993129-14] Fujii K, Mintz GS, Kobayashi Y, Carlier SG, Takebayashi H, Yasuda T; et al. (2004). "Contribution of stent underexpansion to recurrence after sirolimus-eluting stent implantation for in-stent restenosis". Circulation. 109 (9): 1085–8. doi:10.1161/01.CIR.0000121327.67756.19. PMID 14993129.

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@@ Line 19: / Line 19: @@
 ===Pathophysiology===
 *[[Restenosis]] can occur in the implanted [[stent]] after performing [[PCI]].<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
-*Factors such as [[stent]] type, chosen procedure, and [[patient]]-related factors are critical in the [[pathophysiology]] of [[stent]] [[thrombosis]] or [[restenosis]].<ref name="pmid21109112">{{cite journal| author=Dangas GD, Claessen BE, Caixeta A, Sanidas EA, Mintz GS, Mehran R| title=In-stent restenosis in the drug-eluting stent era. | journal=J Am Coll Cardiol | year= 2010 | volume= 56 | issue= 23 | pages= 1897-907 | pmid=21109112 | doi=10.1016/j.jacc.2010.07.028 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21109112  }} </ref><ref name="pmid20946992">{{cite journal| author=Holmes DR, Kereiakes DJ, Garg S, Serruys PW, Dehmer GJ, Ellis SG | display-authors=etal| title=Stent thrombosis. | journal=J Am Coll Cardiol | year= 2010 | volume= 56 | issue= 17 | pages= 1357-65 | pmid=20946992 | doi=10.1016/j.jacc.2010.07.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20946992  }} </ref>
+*The main mechanism causing [[restenosis]] after [[stent]] implication is [[hyperplasia|neointimal hyperplasia]]<ref name="pmid10545431">{{cite journal| author=Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF | display-authors=etal| title=Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome. | journal=Circulation | year= 1999 | volume= 100 | issue= 18 | pages= 1872-8 | pmid=10545431 | doi=10.1161/01.cir.100.18.1872 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10545431  }} </ref><ref name="pmid26341188">{{cite journal| author=Goto K, Zhao Z, Matsumura M, Dohi T, Kobayashi N, Kirtane AJ | display-authors=etal| title=Mechanisms and Patterns of Intravascular Ultrasound In-Stent Restenosis Among Bare Metal Stents and First- and Second-Generation Drug-Eluting Stents. | journal=Am J Cardiol | year= 2015 | volume= 116 | issue= 9 | pages= 1351-7 | pmid=26341188 | doi=10.1016/j.amjcard.2015.07.058 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26341188  }} </ref><ref name="pmid21266707">{{cite journal| author=Kang SJ, Mintz GS, Park DW, Lee SW, Kim YH, Whan Lee C | display-authors=etal| title=Mechanisms of in-stent restenosis after drug-eluting stent implantation: intravascular ultrasound analysis. | journal=Circ Cardiovasc Interv | year= 2011 | volume= 4 | issue= 1 | pages= 9-14 | pmid=21266707 | doi=10.1161/CIRCINTERVENTIONS.110.940320 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21266707  }} </ref><ref name="pmid9884378">{{cite journal| author=Farb A, Sangiorgi G, Carter AJ, Walley VM, Edwards WD, Schwartz RS | display-authors=etal| title=Pathology of acute and chronic coronary stenting in humans. | journal=Circulation | year= 1999 | volume= 99 | issue= 1 | pages= 44-52 | pmid=9884378 | doi=10.1161/01.cir.99.1.44 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9884378  }} </ref>
 *The [[pathophysiology]] of [[restenosis]] can be anticipated based on the time period that [[restenosis]] occurs.<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
 **Early [[stent]] [[thrombosis]] is usually due to residual target-[[lesion]] [[thrombus]], [[stent]] failure, or nonadherence to [[dual antiplatelet therapy]].