Classification and Current Treatment Options of In-Stent Restenosis

Abstract

Coronary stent implantation is currently performed in > 80% of percutaneous coronary interventions. Its main late complication is the development of in-stent restenosis (ISR), occurring in 10-80% of lesions treated in daily practice. The classification by Mehran et al. is most commonly used. Current therapeutic options to treat ISR include repeat balloon angioplasty, repeat stenting, cutting balloon angioplasty, directional coronary atherectomy, rotational coronary atherectomy, brachytherapy, and drug-eluting stents (DES). DES have been effective in reducing binary restenosis in de novo lesions in randomized controlled trials. The novel use of DES to treat ISR has been shown to be safe and effective in multiple studies involving sirolimus- and paclitaxel-eluting stents. As DES implantation becomes more widespread, ISR in DES is emerging as a new problem. The use of debulking techniques to treat ISR in DES is to be cautioned against. In this new era, the optimal treatment of this new problem is currently unknown. We await further data to see whether repeat DES implantation may help solve this vexing clinical problem.

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“…Coronary stent implantation is currently performed in more than 80% of percutaneous coronary interventions. 76 Stenting, which involves implanting a metallic mesh to increase blood flow, is rapidly becoming the preferred technique for the percutaneous treatment of coronary artery disease, since it has significant advantages over angioplasty, the mechanical alteration of narrowed or totally obstructed blood vessels. 77 Stents prevent vessel closure and early vessel recoil and improve the long-term patency of arteries.…”

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“…Paclitaxel binds to microtubules and stabilizes microtubule assembly, inhibiting cell cycles that are dependent on microtubular turnover. It inhibits the proliferation and migration of vascular smooth muscle cells (95). The TAXUS IV trial confirmed the effectiveness of paclitaxel-coated stents on in-stent stenosis reported in earlier trials (96).…”

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“…In addition, most drug-eluting stents are currently available only for cardiac applications. Other options to treat in-stent restenosis have been reported [9], one being intravascular radiation called brachytherapy, in which special catheters are used to apply radiation to diseased sites to destroy in-stent tissue. Although this approach has been successful in limiting restenosis [10], various practical issues related to the safety and the needs for special facilities prevent its widespread application [11].…”

“…Other mechanical techniques that use catheters equipped with cutting tools (cutting balloons, rotational atherectomy, etc.) to remove restenotic lesions have been reported [9]. However, their use is limited mainly due to their inherent risk of vessel perforation.…”

“…However, their use is limited mainly due to their inherent risk of vessel perforation. Repeated angioplasty or placement of another stent may be performed; however, these methods involve high recurrence rates [9], [12] while not offering fundamental solutions to the problem. Another limiting factor of all these measures is the need for interventional, invasive procedures with catheter insertion.…”