PCI complications: restenosis: Difference between revisions
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==Restenosis== | ==Restenosis== | ||
===Overview=== | ===Overview=== | ||
===Classification=== | ===Classification=== | ||
<ref name="pmid10545431">{{cite journal| author=Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF et al.| 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= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10545431 }} </ref>'' | The following are the one of the classifications:<ref name="pmid10545431">{{cite journal| author=Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF et al.| 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= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10545431 }} </ref>'' | ||
* Pattern I: Focal (≤ 10 mm in length) [[lesion]]s | * Pattern I: Focal (≤ 10 mm in length) [[lesion]]s | ||
** Ia : [[Restenosis]] within the [[stent]] | ** Ia : [[Restenosis]] within the [[stent]] | ||
| Line 24: | Line 18: | ||
*[[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> | *[[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> | *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 [[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]]. | |||
**Late [[stent]] [[thrombosis]] is usually associated with inadequate neointimal coverage or incomplete healing. | |||
===Epidemiology and Demographics=== | ===Epidemiology and Demographics=== | ||
| Line 35: | Line 32: | ||
*[[Restenosis]] after [[DES|drug eluting stent]] implantation is generally more focal than following [[bare metal stent]] placement<ref name="pmid15596568">{{cite journal| author=Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M et al.| title=Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries. | journal=Circulation | year= 2004 | volume= 110 | issue= 25 | pages= 3773-80 | pmid=15596568 | doi=10.1161/01.CIR.0000150331.14687.4B | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15596568 }} </ref><ref name="pmid12719283">{{cite journal| author=Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M et al.| title=Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation. | journal=Circulation | year= 2003 | volume= 107 | issue= 17 | pages= 2178-80 | pmid=12719283 | doi=10.1161/01.CIR.0000070592.04766.36 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12719283 }} </ref>, 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]]<ref name="pmid15596568">{{cite journal| author=Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M et al.| title=Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries. | journal=Circulation | year= 2004 | volume= 110 | issue= 25 | pages= 3773-80 | pmid=15596568 | doi=10.1161/01.CIR.0000150331.14687.4B | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15596568 }} </ref><ref name="pmid12719283">{{cite journal| author=Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M et al.| title=Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation. | journal=Circulation | year= 2003 | volume= 107 | issue= 17 | pages= 2178-80 | pmid=12719283 | doi=10.1161/01.CIR.0000070592.04766.36 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12719283 }} </ref><ref name="pmid12860901">{{cite journal| author=Lemos PA, Saia F, Ligthart JM, Arampatzis CA, Sianos G, Tanabe K et al.| title=Coronary restenosis after sirolimus-eluting stent implantation: morphological description and mechanistic analysis from a consecutive series of cases. | journal=Circulation | year= 2003 | volume= 108 | issue= 3 | pages= 257-60 | pmid=12860901 | doi=10.1161/01.CIR.0000083366.33686.11 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12860901 }} </ref>. | *[[Restenosis]] after [[DES|drug eluting stent]] implantation is generally more focal than following [[bare metal stent]] placement<ref name="pmid15596568">{{cite journal| author=Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M et al.| title=Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries. | journal=Circulation | year= 2004 | volume= 110 | issue= 25 | pages= 3773-80 | pmid=15596568 | doi=10.1161/01.CIR.0000150331.14687.4B | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15596568 }} </ref><ref name="pmid12719283">{{cite journal| author=Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M et al.| title=Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation. | journal=Circulation | year= 2003 | volume= 107 | issue= 17 | pages= 2178-80 | pmid=12719283 | doi=10.1161/01.CIR.0000070592.04766.36 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12719283 }} </ref>, 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]]<ref name="pmid15596568">{{cite journal| author=Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M et al.| title=Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries. | journal=Circulation | year= 2004 | volume= 110 | issue= 25 | pages= 3773-80 | pmid=15596568 | doi=10.1161/01.CIR.0000150331.14687.4B | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15596568 }} </ref><ref name="pmid12719283">{{cite journal| author=Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M et al.| title=Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation. | journal=Circulation | year= 2003 | volume= 107 | issue= 17 | pages= 2178-80 | pmid=12719283 | doi=10.1161/01.CIR.0000070592.04766.36 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12719283 }} </ref><ref name="pmid12860901">{{cite journal| author=Lemos PA, Saia F, Ligthart JM, Arampatzis CA, Sianos G, Tanabe K et al.| title=Coronary restenosis after sirolimus-eluting stent implantation: morphological description and mechanistic analysis from a consecutive series of cases. | journal=Circulation | year= 2003 | volume= 108 | issue= 3 | pages= 257-60 | pmid=12860901 | doi=10.1161/01.CIR.0000083366.33686.11 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12860901 }} </ref>. | ||
===Diagnosis=== | ===Diagnosis=== | ||
*It is necessary to evaluate the underlying cause of [[stent]] [[thrombosis]] with [[coronary|intracoronary]] imaging ([[IVUS]] and [[OCT]]) in order to plan the proper [[treatment]].<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="pmid14993129">{{cite journal| author=Fujii K, Mintz GS, Kobayashi Y, Carlier SG, Takebayashi H, Yasuda T | display-authors=etal| title=Contribution of stent underexpansion to recurrence after sirolimus-eluting stent implantation for in-stent restenosis. | journal=Circulation | year= 2004 | volume= 109 | issue= 9 | pages= 1085-8 | pmid=14993129 | doi=10.1161/01.CIR.0000121327.67756.19 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14993129 }} </ref> | |||
*In the setting of in-[[stent]] [[restenosis]] (ISR) after [[bare metal stent|bare metal stent (BMS)]] implantation, the risk of recurrence can be predicted by the pattern of [[restenosis]]. | |||
==2021 ACA Guidline Recommendations== | ==2021 ACA Guidline Recommendations== | ||
Revision as of 15:11, 3 July 2022
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Percutaneous coronary intervention Microchapters |
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PCI complications: restenosis On the Web |
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Risk calculators and risk factors for PCI complications: restenosis |
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
Pathophysiology
- Restenosis can occur in the implanted stent after performing PCI.[2]
- Factors such as stent type, chosen procedure, and patient-related factors are critical in the pathophysiology of stent thrombosis or restenosis.[3][4]
- 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.
Epidemiology and Demographics
Causes
- Risk of ISR is lowered after presentation of new generations stents such as DES compared to BMS and first-generation DES.[5][6]
Natural History, Complications and Prognosis
- 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].
- Restenosis after drug eluting stent implantation is generally more focal than following bare metal stent placement[7][8], 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[7][8][9].
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.[3][10]
- 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 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). - ↑ 3.0 3.1 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.
- ↑ 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.
- ↑ 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.
- ↑ 7.0 7.1 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.
- ↑ 8.0 8.1 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.
- ↑ 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.