21 Re-Stenosed Stents in the Presence of Adequate P2Y12 Inhibition: A Case Report

Abstract

In-stent restenosis (ISR) is an important complication observed after stent implantation with percutaneous coronary intervention (PCI) and is clinically defined as the onset of recurrent angina symptoms or objective evidence of myocardial ischemia.Angiographically, it is defined by ≥50% luminal diameter stenosis in the stented segment. The incidence of ISR varies with the type of stent used, patient and lesion characteristics, and procedural factors. The patient-related factors associated with late ISR (>30 days) include poor response to antiplatelet drugs, diabetes, malignancy, renal failure, and acute coronary syndrome (ACS) at presentation [1]. Higher rates of ISR are seen with increasing complexity of lesions. Data from meta-analysis and registries show a similar rate of early (<30 days) and late (>30 days but less than 1 year) ISR between bare-metal stents (BMS) and first-generation drug eluting stents (DES) [2,3]. With introduction of second-generation DES, rates of ISR have been reduced to 1.5% -2.3% at 1 year [4,5]. The underlying pathophysiology of DES-ISR involves a complex interplay between platelets, leukocytes, coagulationfibrinolysis system, various growth factors and pro-inflammatory cytokines. We present a case of a patient who underwent ISR in 21 stents despite being on adequate P2Y12 inhibition. This case highlights the role of coagulation pathways other than platelets in pathogenesis of ISR. Case Presentation 67-year-old Caucasian woman with past medical history of diabetes type 2, hypertension, peripheral vascular disease and severe coronary artery disease status post coronary artery bypass grafting 12 years ago (saphenous vein graft [SVG] to the first and third marginal branches of left circumflex artery, SVG to