Related Experiment Videos
Angiographic patterns of in-stent restenosis and implications on subsequent revascularization
1Cardiac Catheterization Laboratory, the Zena & Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY 10029, USA.
Insights
In-stent restenosis (ISR) patterns predict repeat intervention success. Diffuse ISR, common in diabetics, has higher target lesion revascularization rates and may benefit from rotational atherectomy over balloon angioplasty.
Area of Science:
- Cardiovascular Interventions
- Interventional Cardiology
- Biomedical Engineering
Background:
- Stent implantation is standard for coronary lesions.
- In-stent restenosis (ISR) occurs in 6%-40% of procedures.
- Angiographic patterns of ISR may predict outcomes of repeat interventions.
Purpose of the Study:
- To evaluate the incidence and predictors of ISR angiographic patterns.
- To assess the impact of ISR patterns on target lesion revascularization (TLR).
Main Methods:
- Study included 100 consecutive patients with Palmaz-Schatz ISR undergoing intervention.
- Evaluated angiographic patterns (diffuse vs. focal) and clinical/angiographic predictors.
- Compared TLR rates and outcomes with different revascularization strategies.
Main Results:
- Diffuse ISR (>=10 mm) was observed in 78% of patients, focal ISR (>10 mm) in 22%.
- Diffuse ISR occurred earlier, was more common in diabetics, and associated with specific angiographic predictors.
- TLR was significantly higher for diffuse ISR (46%) compared to focal ISR (14%).
- Rotational atherectomy showed lower TLR (31%) than PTCA/restent (64%) for diffuse ISR.
Conclusions:
- Diffuse ISR is more prevalent than focal ISR and linked to aggressive intimal hyperplasia.
- Clinical and angiographic variables can predict diffuse ISR.
- Diffuse ISR responds poorly to standard balloon angioplasty (PTCA) and may benefit from debulking strategies like rotational atherectomy.
Abstract:
Stent implantation has become the mainstay of percutaneous revascularization for most coronary lesions; in-stent restenosis (ISR) can occur in 6%-40% of stent procedures and the subsequent response to repeat intervention can possibly be predicted by the angiographic patterns of ISR. This study evaluated the incidence and predictors of angiographic patterns of ISR and its impact on subsequent target lesion revascularization (TLR) in 100 consecutive patients having Palmaz-Schatz ISR undergoing intervention. Diffuse ISR (>/=10 mm) was observed in 78% and focal ISR (>10 mm) in 22%. Diffuse vs. focal ISR occurred earlier after stent implantation and was more common in diabetics. Angiographic predictors of diffuse ISR were stent implantation for a restenotic lesion, long lesions, smaller vessel, stenting without debulking, and high-pressure balloon inflation (>16 atm). TLR after repeat intervention was 46% for diffuse and 14% for focal ISR (P < 0.02). Rotational atherectomy resulted in lower TLR (31%) vs. PTCA or restent (64%) in diffuse ISR (P < 0.004). Therefore, diffuse ISR is more common than focal ISR, usually occurs in the setting of aggressive intimal hyperplasia, and can be predicted by clinical and angiographic variables. Also, diffuse intimal hyperplasia within a stent responds poorly to PTCA and may benefit from a more aggressive debulking strategy such as rotational atherectomy. Cathet. Cardiovasc. Intervent. 49:23-29, 2000.