Switching types of drug-eluting stents does not prevent repeated in-stent restenosis in patients with coronary drug-eluting stent restenosis

Abstract

ObjectivesWe treated patients experiencing drug-eluting stent (DES) restenosis with plain old balloon angioplasty (POBA), implantation of the same type of DES [homogeneous drug-eluting stent (HOMO-DES)], or implantation of a different type of DES [heterogeneous drug-eluting stent (HETERO-DES)], and compared the efficacy and safety of these procedures for the prevention of repeated in-stent restenosis (ISR).BackgroundIn patients with de-novo coronary lesions, DES implantation is associated with a markedly reduced restenosis rate as compared with that associated with a bare metal stent and POBA. However, the optimal management strategy for patients with DES ISR remains unknown.Patients and methodsWe identified 191 consecutive DES ISR lesions from 183 patients who required clinically driven revascularization and divided them into three groups according to the treatment: 38 lesions were treated with POBA, 38 with HOMO-DES, and 115 with HETERO-DES.ResultsThe incidence of target lesion revascularization (TLR) was 42.1% (16/38), 15.8% (6/38), and 16.5% (19/115) in the POBA, HOMO-DES, and HETERO-DES groups (POBA vs. HOMO, HETERO-DES; P=0.002, respectively). Multivariate analysis indicated that diabetes [odds ratio (OR), 3.4], hemodialysis (OR, 7.74), nonfocal ISR patterns (OR, 3.35), previous myocardial infarction (OR, 3.26), and POBA (OR, 8.84) were independent predictors of TLR.ConclusionA strategy involving repeated DES implantation was superior to POBA for preventing recurrent restenosis. Treatment with a different type or generation of DES does not appear to reduce the incidence of TLR. Moreover, we identified certain useful factors for facilitating appropriate and early triage in the patients with repeated DES ISR.

Same or Different Drug‐Eluting Stent Re‐Implantation for Drug‐Eluting Stent Restenosis: An Assessment Including Second‐Generation Drug‐Eluting Stents

“…The drug‐specific factors may inhibit greater formation of intimal hyperplasia in stents using different DESs when compared to that using the same DESs. Taking into account these contributing factors, several investigations have examined the treatment of DES‐ISR using different types of DES re‐implantation, but failed to show a significant improvement compared to the same type of DES . A limited paper reported by Mishkel et al demonstrated treatment with a different DES for DES‐ISR tended to result in better 12‐month outcomes than with the same DES, though it was not statistically significant.…”

“…Taking into account these contributing factors, several investigations have examined the treatment of DES-ISR using different types of DES re-implantation, but failed to show a significant improvement compared to the same type of DES. [12][13][14]23 A limited paper reported by Mishkel et al 24 demonstrated treatment with a different DES for DES-ISR tended to result in better 12-month outcomes than with the same DES, though it was not statistically significant. Most of those studies were conducted to investigate a cohort treated in the first-generation DES era.…”

When Less is More: Drug-Coated Balloons Threaten a Paradigm Revolution

“…When the DES arm was considered alone, drug-switching still showed an advantage (HR 0.35, CI 0.15-0.79, P = 0.012). However, this finding should not be considered definitive because it was not a pre-specified analysis and prior studies have produced conflicting results regarding the benefit of a drug-switching strategy [7][8][9].…”

Response to drug-eluting stent in-stent restenosis and re-restenosis: A hard time story

“…According to the institutional protocols, and as previously noted in our study methods, a switch strategy (Hetero-DES) was adopted in all cases, including those with DES re-restenosis. Nevertheless, whether or not to adopt a switch strategy in DES-associated restenosis is still a matter of debate [2], [3], even with second-generation DES [4].…”