PCI in the patient with in stent restenosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Synonyms: ISR
Background
In-stent restenosis (ISR) is the most frequent late complication of stent implantation. It occurs when there is a reoccurrence of stenosis around a lesion that has been treated with a stent, and it results from exaggerated neointimal formation and is principally composed of smooth muscle cells and extracellular matrix. Although ISR has traditionally occurred in 10-80% of treated lesions, its incidence has been dramatically reduced by the development of drug-eluting stents.
Certain factors are known to increase the risk of in-stent restenosis, which can be grouped into those that are related to the patient, the lesion, and the procedure. Patients with diabetes mellitus and chronic kidney disease are at an increased risk of ISR. Lesions with a great lesion length, small vessel diameter, total plaque burden, chronic total occlusion, ostial location, and/or vein graft lesion are more likely to experience in-stent restenosis. Additionally, procedure-related factors that increase the risk of ISR include a residual stenosis >30%, a residual pressure gradient >20mmHg, and 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 thrombosis, and had fallen out of favor.