Efficacy of Various Percutaneous Interventions for In-Stent Restenosis

Sethi, Ankur; Malhotra, Gurveen; Singh, Sukhchain; Singh, Param; Khosla, Sandeep

doi:10.1161/circinterventions.115.002778

Cited by 27 publications

(11 citation statements)

References 42 publications

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“…This analysis suggested that PCI with second-generation DES (EES) was the most effective treatment, whereas percutaneous coronary intervention with DEB was ranked as the second most effective treatment but without significant differences from first-generation DES. Two additional similar design meta-analyses have reported similar findings suggesting second generation DES as treatment of choice for BMS and DES-ISR[ 74 , 75 ]. As a result, the 2009 update of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions guideline update for PCI and the 2005 European Society of Cardiology Task Force recommend DES for ISR whether the initial stent was BMS or DES[ 76 - 78 ].…”

Section: Treatmentmentioning

confidence: 80%

Diagnosis and management challenges of in-stent restenosis in coronary arteries

Alraies

Darmoch

Tummala

et al. 2017

WJC

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Over the course of the 3 decades, percutaneous coronary intervention (PCI) with stent implantation transformed the practice of cardiology. PCI with stenting is currently the most widely performed procedure for the treatment of symptomatic coronary disease. In large trials, drug-eluting stents (DES) have led to a significant reduction in in-stent restenosis (ISR) rates, one of the major limitations of bare-metal stents. Due to these favorable findings, DES was rapidly and widely adopted enabling more complex coronary interventions. Nevertheless, ISR remains a serious concern as late stent complications. ISR mainly results from aggressive neointimal proliferation and neoatherosclerosis. DES-ISR treatment continues to be challenging complications for interventional cardiologists.

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Section: Treatmentmentioning

confidence: 80%

Diagnosis and management challenges of in-stent restenosis in coronary arteries

Alraies

Darmoch

Tummala

et al. 2017

WJC

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“…Although ISR is less common after introduction of the DES, the treatment of ISR still remains a challenge [ 11 ]. It usually presents as recurrent angina and has often been managed by repeat percutaneous revascularization including balloon angioplasty with either a non-compliant or scoring balloon, DCB angioplasty, additional DES implantation, and surgical revascularization.…”

Section: Discussionmentioning

confidence: 99%

The impact of tissue characterization for in-stent restenosis with optical coherence tomography during excimer laser coronary angioplasty

Hashimoto

Takahashi

Mizuguchi

et al. 2018

Cardiovasc Interv and Ther

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We aimed to evaluate the impact of tissue characterization for in-stent restenosis (ISR) with optical computed tomography (OCT) during excimer laser coronary angioplasty (ELCA) in the drug-eluting stent (DES) era. The effect of ELCA for ISR according to differences in tissue characteristics is unclear. Fifty-three ISR lesions (7 bare metal stents and 46 drug-eluting stents) were treated with an ELCA catheter. After ELCA, balloon dilatation with either the scoring or non-compliant balloons was conducted. The procedure was completed by applying a drug-coated balloon. Tissue characterization and lumen measurement with OCT were performed thrice: (1) before percutaneous coronary intervention (PCI), (2) after ELCA, and (3) and after the procedure. Lesions were categorized into the homogenous, layered, and mixed groups. Follow-up angiograms were conducted 6-12 months after PCI. No significant differences in minimal lumen area (MLA) were observed before PCI. A significant difference was observed in MLA after ELCA among the three groups (homogeneous group: 1.75 ± 0.84 mm, layered group: 1.72 ± 0.45 mm, mixed group: 2.24 ± 0.70 mm, P = 0.048). Final MLA was larger in the mixed group than in the homogeneous group (P = 0.028). No significant difference was observed in binary restenosis in the follow-up angiogram (homogeneous group 55.5%, layered group 33.3%, mixed group 33.3%; P = 0.311) and the target lesion revascularization rate (homogeneous 30.0%, layered 23.8%, mixed 25.0%; P = 0.923). Tissue characterization by OCT may predict the efficacy of ELCA and balloon angioplasty for ISR during the acute phase.

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“…9 Two additional similar design meta-analyses have reported similar findings. 10,11 In this issue of Circulation: Cardiovascular Interventions, Alfonso et al 12 presents a pooled analysis of the RIBS V (Restenosis Intra-Stent of Bare Metal Stents: Paclitaxel-Eluting Balloon vs Everolimus-Eluting Stent) and RIBS IV (Restenosis Intra-Stent of Drug-Eluting Stents: Paclitaxel-Eluting Balloon vs Everolimus-Eluting Stent) multicenter randomized trials, 6,7 comparing the efficacy of EES in patients with BMS-ISR and DES-ISR. The study detected clinical and morphological differences of ISR in BMS versus DES, including for the later more focal ISR pattern and delayed onset of presentation.…”

Section: See Article By Alfonso Et Almentioning

confidence: 99%

In-Stent Restenosis?

Waksman

Steinvil

2016

Circ: Cardiovascular Interventions

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T he introduction of bare metal stents (BMS) over 30 years ago was a significant milestone in the evolution of percutaneous coronary intervention. Soon after, it was apparent that these stents led to a troubling phenomenon of in-stent restenosis (ISR), which requires repeat revascularization, was associated with increased morbidity and mortality, and posed a therapeutic challenge. The quest for optimal therapy for ISR has begun, but in parallel, continued efforts were devoted to improve the stent technology. These iterations included design and alloy modification, reducing strut thickness, and adding a polymer to elute an antiproliferative drug. Drug-eluting stents (DES) significantly reduced the occurrence of exuberant neointimal proliferation.1 However, in spite of the wide use and experience gained with novel stent technologies and implantation techniques, the rates of ISR in both BMS and DES are still relatively high.2 In a contemporary report on a large cohort (n=10 004), routine angiographic surveillance 6 to 8 months after stent implantation has revealed ISR rates of 30.1%, 14.6%, and 12.2% for BMS, first-generation DES, and second-generation DES, respectively. 3 See Article by Alfonso et alTo optimize the treatment of ISR, it is imperative to identify and understand the major etiologies for ISR that have been traditionally classified and characterized as (1) operator or technique dependent, including stent undersizing, incomplete lesion coverage, stent under expansion, and malapposition; (2) mechanical and design properties of stents that may lead to recoil because of loss of radial force, stent fractures, and altering increase in shear stress; (3) patient-and biologically related conditions, such as metal allergy, local hypersensitivity reactions with immunologic and inflammatory response to the drug or the polymer, often characterized with inflammatory cells and smooth muscle cells that transformed to rigid scar tissue within the stent. This local inflammation can lead to the development of neoatherosclerosis characterized by accumulation of lipid-laden foamy macrophages within the neointima with or without a necrotic core formation and calcification, which can occur years after stent placement. 4 With the introduction of DES, it was apparent that there are differences with respect to the time course and the phenotypic appearance of ISR across the BMS and DES generations, exhibiting a more diffuse and proliferative pattern for BMS versus more focal and soft lesions for the DES, however, more resistant to treatment. 4 Neoatherosclerosis occurs more frequently and at an earlier time in the first-and second-generation DES when compared with BMS.2 These mechanistic complexities make the treatment of ISR even more challenging because both mechanical and biological factors can influence treatment outcomes.Over the years, there were many attempts to find an optimal therapy for ISR; among them there were the high-pressure balloons, scoring balloons, ablative therapy with laser and rotational atherectomy device...

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Efficacy of Various Percutaneous Interventions for In-Stent Restenosis

Cited by 27 publications

References 42 publications

Diagnosis and management challenges of in-stent restenosis in coronary arteries

Diagnosis and management challenges of in-stent restenosis in coronary arteries

The impact of tissue characterization for in-stent restenosis with optical coherence tomography during excimer laser coronary angioplasty

In-Stent Restenosis?

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