Korean Circ J.  2009 Oct;39(10):408-413. 10.4070/kcj.2009.39.10.408.

Therapeutic Strategy for In-Stent Restenosis Based on the Restenosis Pattern After Drug-Eluting Stent Implantation

• Kim KH
• Kim DI
• Kim IH
• Kim JY
• Han YC
• Seol SH
• Kim U
• Yang TH
• Kim DK
• Kim DS
• Lee SH
• Park JS
• Kim YJ
• Shin DG
• Cho YK
• Nam CW
• Hur SH
• Kim KB

• KMID: 2028920
• DOI: http://doi.org/10.4070/kcj.2009.39.10.408

Abstract

BACKGROUND AND OBJECTIVES
The aim of this study was to evaluate the outcomes of repeated percutaneous coronary intervention (PCI) based on the restenosis pattern in drug-eluting stent (DES) failure. SUBJECTS AND METHODS: From April 2003 to March 2006, all 67 patients (67 lesions) at our 3 centers who had DES in-stent restenosis (ISR) were enrolled. The patients were divided into 3 groups: group I had focal edge restenosis, group II had focal body restenosis, and group III had non-focal restenosis. All patients were treated with conventional PCI including plain old balloon angioplasty (POBA), cutting balloon angioplasty (CBA), and repeated DES implantation (Re-DES). Angiographic and clinical one year follow-up results for the 3 groups were evaluated. RESULTS: Sixteen patients were enrolled in group I, 36 in group II, and 15 in group III. Baseline clinical and angiographic characteristics and the proportion of patients in each group receiving each type of treatment strategy were not significantly different among the groups. Within each group, a comparison of angiographic and clinical outcomes for each therapeutic modality revealed that restenosis rates were not statistically different. Although rates of major adverse cardiac events (MACE) were not statistically different between groups I and II, in group III, MACE were 3-fold higher for the POBA (4/4, 100.0%) and CBA (4/4, 100.0%) subgroups than for Re-DES (1/3, 33.3%) (p=0.06), but the differences did not reach statistical significance. CONCLUSION: The present study suggests that treatment of DES ISR should be individualized according to restenosis pattern: any PCI strategy appears appropriate for focal ISR patterns, while Re-DES might be a better choice for non-focal ISR patterns.

Keyword

Percutaneous transluminal coronary angioplasty; Restenosis; Drug-eluting stent; Coronary restenosis

MeSH Terms

Angioplasty, Balloon
Angioplasty, Balloon, Coronary
Coronary Restenosis
Drug-Eluting Stents
Follow-Up Studies
Humans
Percutaneous Coronary Intervention

Reference

1. Costa MA, Simon DI. Molecular basis of restenosis and drug-eluting stents. Circulation. 2005. 111:2257–2273.

2. Costa MA. Treatment of drug-eluting stent restenosis. Am Heart J. 2007. 153:447–449.

3. Solinas E, Dangas G, Kirtane AJ, et al. Angiographic patterns of drug-eluting stent restenosis and one-year outcomes after treatment with repeated percutaneous coronary intervention. Am J Cardiol. 2008. 102:311–315.

4. Kim YH, Lee BK, Park DW, et al. Comparison with conventional therapies of repeated sirolimus-eluting stent implantation for the treatment of drug-eluting coronary stent restenosis. Am J Cardiol. 2006. 98:1451–1454.

5. Steinberg DH, Pinto Slottow TL, Buch AN, et al. Impact of instent restenosis on death and myocardial infarction. Am J Cardiol. 2007. 100:1109–1113.

6. Lee SR, Jeong MH, Lim SY, et al. Comparison of the clinical effect of cutting balloon angioplasty and drug-eluting stent for treating the focal type of in-stent restenosis. Korean Circ J. 2006. 36:279–284.

7. Cosgrave J, Melzi G, Corbett S, et al. Repeated drug-eluting stent implantation for drug-eluting stent restenosis: the same or a different stent. Am Heart J. 2007. 153:354–359.

8. Moussa ID, Moses JW, Kuntz RE, et al. The fate of patients with clinical recurrence after sirolimus-eluting stent implantation (a two-year follow-up analysis from the SIRIUS trial). Am J Cardiol. 2006. 97:1582–1584.

9. Airoldi F, Briguori C, Iakovou I, et al. Comparison of sirolimus versus paclitaxel eluting stents for treatment of coronary in-stent restenosis. Am J Cardiol. 2006. 97:1182–1187.

10. Lee HG, Chun KJ, Cho KI, et al. Impact of drug-eluting stents on clinical outcomes in patients with diffuse coronary lesions. Korean Circ J. 2008. 38:612–617.

11. Cosgrave J, Melzi G, Biondi-Zoccai GG, et al. Drug-eluting stent restenosis the pattern predicts the outcome. J Am Coll Cardiol. 2006. 47:2399–2404.

12. Sukhija R, Aronow WS, Sureddi R, et al. Predictors of in-stent restenosis and patient outcome after percutaneous coronary intervention in patients with diabetes mellitus. Am J Cardiol. 2007. 100:777–780.

13. Eisenberg MJ, Konnyu KJ. Review of randomized clinical trials of drug-eluting stents for the prevention of in-stent restenosis. Am J Cardiol. 2006. 98:375–382.

14. Mitra AK, Agrawal DK. In stent restenosis: bane of the stent era. J Clin Pathol. 2006. 59:232–239.

15. Yang TH, Kim DI, Park SG, et al. Clinical characteristics of stent fracture after sirolimus-eluting stent implantation. Int J Cardiol. 2009. 131:212–216.

16. Aoki J, Nakazawa G, Tanabe K, et al. Incidence and clinical impact of coronary stent fracture after sirolimus-eluting stent implantation. Catheter Cardiovasc Interv. 2007. 69:380–386.

17. Mehran R, Dangas G, Abizaid AS, et al. Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome. Circulation. 1999. 100:1872–1878.

18. Albiero R, Silber S, Di Mario C, et al. Cutting balloon versus conventional balloon angioplasty for the treatment of in-stent restenosis: results of the restenosis cutting balloon evaluation trial (RESCUT). J Am Coll Cardiol. 2004. 43:943–949.

19. Airoldi F, Rogacka R, Briguori C, et al. Comparison of clinical and angiographic outcome of sirolimus-eluting stent implantation versus cutting balloon angioplasty for coronary in-stent restenosis. Am J Cardiol. 2004. 94:1297–1300.

20. Liistro F, Fineschi M, Angioli P, et al. Effectiveness and safety of sirolimus stent implantation for coronary in-stent restenosis: the TRUE (Tuscany Registry of Sirolimus for Unselected In-Stent Restenosis) Registry. J Am Coll Cardiol. 2006. 48:270–275.

21. Alfonso F, Perez-Vizcayno MJ, Hernandez R, et al. A randomized comparison of sirolimus-eluting stent with balloon angioplasty in patients with in-stent restenosis: results of the Restenosis Intrastent: Balloon Angioplasty Versus Elective Sirolimus-Eluting Stenting (RIBS-II) trial. J Am Coll Cardiol. 2006. 47:2152–2160.

22. Kastrati A, Mehilli J, von Beckerath N, et al. Sirolimus-eluting stent or paclitaxel-eluting stent vs balloon angioplasty for prevention of recurrences in patients with coronary in-stent restenosis: a randomized controlled trial. JAMA. 2005. 293:165–171.