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Challenges of in-stent restenosis

Despite recent advances with drug eluting stent (DES) technology instent restenosis (ISR) still represents a clinically relevant failure of percutaneous coronary intervention.

  • Facing up to the problem, presented by P Kala (Brno, CZ) - Slides
  • Pathophysiology and predictors, presented by I Iakovou (Athens, GR) - Slides
  • The balloon approach, presented by B Scheller (Homburg/Saar, DE) - Slides
  • The stent approach, presented by B Chevalier (Massy, FR) - Slides
Acute Coronary Syndromes (ACS)

In the first part of the session P. Kala (Brno, CZ) and I. Iakovou (Athens, GR) review the extent of the problem and the pathophysiological background. It was emphasized, that ISR is not a benign disease, since 30 – 60% of patients with ISR present with a prognostically unfavourable acute coronary syndrome. With DES, overall restenosis rate could be reduced from 30% to below 10%, but the actual restenosis risk still varies between patients. Procedural factors predisposing for restenosis are incomplete stent expansion (stent size), geographic mismatch and the use of multiple stents whereas stent technique factors include polymer characteristics, strut coverage and stent fractures. Patient related factors predisposing for ISR are lesion-specific such as bifurcations, ostial lesions or vein graft as well as biological factors such as diabetes or – clinically less assessable – drug resistance or hypersensitivity.

The best way to treat ISR is to prevent it, which is not only possible by using DES. Furthermore, an accurate PCI technique with thoughtful target selection, adequate choice of stent size and implantation pressure is beneficial. It was emphasized that routine use of pressure wire (FFR measurement), especially in patients with multivessel disease, would identify lesions, which would not have to be treated (and therefore cannot develop ISR).

In the second part, B. Scheller (Homburg, Germany) and B. Chevalier (Massy, France) reviewed current treatment options for ISR. Meanwhile, additional DES implantation is the established way to treat ISR, for both failure of a BMS or a DES. Compared to only balloon angioplasty, recurrent (second) ISR can be reduced by 65% with an additional DES. However, to have multiple layers of stent struts in the coronary artery may be a limit to this approach. Therefore, drug eluting balloons (DEB) may be a favourable alternative to treat ISR, which has been also considered in the recent 2010 ESC revascularization guidelines. First small studies indicate that DEB may reduce second ISR to below 10% with DEB, compared to 20% with DES or 50% with balloon angioplasty only. However, these results have to be confirmed in ongoing larger trials, powered for clinical endpoints. In addition, class effect of DEB may not be assumed and therefore, only DEB adequately evaluated in clinical trials may be used.




Challenges of in-stent restenosis

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.