[Curative treatment of restenosis]

It has been clearly demonstrated that post-angioplasty restenosis is the result of the combination of three distinct mechanisms associated to different degrees: constrictive remodelling, neo-intimal hyperplasia and elastic recoil. In contrast, after stent implantation, constrictive remodelling is nil, elastic recoil is very mild and restenosis, when observed, is essentially due to a reaction of intimal hyperplasia. These physiopathological features are important as they affect the therapeutic opportunities. With rates of stent implantation attaining 100% in some centres, intra-stent restenosis is a new pathology which poses serious problems in everyday practice as the best management of this situation has not yet been determined. For a long time, redilatation with a balloon catheter was the only possible solution. Secondarily, ablative techniques were evaluated, such as rotational and laser atherectomy, techniques with the theoretic advantage of eliminating part of the intimal proliferation. Directional atherectomy has also been used by some groups. More recently, other approaches, such as implantation of a second stent inside the first, the cutting balloon and radiotherapy, have been suggested. A surgical option is always possible in cases of repeat and/or diffuse restenosis. Finally, abstention from any local treatment may be justified in asymptomatic patients. These different approaches are discussed in this paper.