PCI complications: restenosis
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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]
- 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.
- Restenosis after drug eluting stent implantation is generally more focal than following bare metal stent placement[5][6], 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[5][6][7].
Epidemiology and Demographics
ISR is found in 5% to 10% of patients undergoing PCI.[3][8]
Causes
- Risk of ISR is lowered after presentation of new generations stents such as DES compared to BMS and first-generation DES.[9][10]
- Factors such as stent type, chosen procedure, and patient-related factors are critical in the pathophysiology of stent thrombosis or restenosis.[3][4]
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.[3][11]
- 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 3.2 3.3 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.
- ↑ 4.0 4.1 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.
- ↑ 5.0 5.1 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.
- ↑ 6.0 6.1 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.
- ↑ 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.
- ↑ 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.