Practical Management in Coronary In-Stent Restenosis: A Narrative Review

Area of Science:

• Cardiology
• Interventional Cardiology
• Biomedical Engineering

Background:

• Coronary in-stent restenosis (ISR) is a significant challenge after percutaneous coronary intervention, often necessitating repeat revascularization despite advances in drug-eluting stent (DES) technology.
• The complex interplay of mechanical, biological, and procedural factors contributes to ISR, highlighting the need for a mechanism-guided management strategy.

Purpose of the Study:

• To provide a contemporary, mechanism-guided approach to the practical management of coronary ISR.
• To review current definitions, classifications, risk factors, and pathophysiology of ISR.
• To critically evaluate evidence-based treatment strategies and propose a practical management framework.

Main Methods:

• This narrative review synthesizes current literature on coronary ISR.
• It summarizes classification systems (Mehran, Waksman, SCAI 2023) and risk factors.
• It discusses the role of intracoronary imaging (IVUS, OCT) and reviews treatment options including drug-coated balloons (DCB), repeat DES, and surgical revascularization.

Main Results:

• Understanding ISR mechanisms (neointimal hyperplasia, neoatherosclerosis) is crucial for treatment selection.
• Intracoronary imaging is central for ISR characterization and treatment planning, though randomized trial data for hard outcomes is limited.
• Evidence-based therapies including DCB and repeat DES offer viable options, with treatment choice depending on ISR type, lesion pattern, and patient factors.

Conclusions:

• A practical, substrate-driven management framework for coronary ISR is proposed, aligning with current international guidelines.
• Future research should focus on ISR-specific randomized trials with hard clinical endpoints and prospective validation of imaging-guided algorithms.
• Further investigation into pharmacological strategies targeting neoatherosclerosis is warranted.