In-Stent RestenosisCoronary artery disease

In stent restenosis

• The biggest challenge in coronary angioplasty

Keywords

• PBA:Plain balloon angioplasty• BMS:Bare metal stent• DES:Drug eluting stent • SE:Serolimous eluting• PE:Paclitaxel eluting• DCB:Drug coated balloon• Neointima: Smooth cell proliferation• Neoatherosclerosis: Lipid plaque inside the stent

Restenosis rate

POBA BMS DES30-50% 20-30% <10%

What does happen after stenting ?

Pathology BMS DES

Imageology

CAGOCT

DiffuseHomogeneous, high signal band most common

FocalLayered structure/heterogeneous most common

Histopathology

Gross lumen over time Neointima Proteoglycan content Peri-strut

fibrin/Inflammation Complete

endothelialisation Thrombus present Neoatherosclerosis

Late loss maximal by 6–8 monthsRichModerateOccasional 3–6 monthsOccasionalRelatively infrequent, late

Ongoing late loss out to 5 yearsHypo cellularHighFrequentUp to 4 yrs.OccasionalRelatively frequent, accelerated course

Prescription

1. Conventional Balloon Angioplasty2. Cutting Balloon: Prevents “watermelon seeding”3. Scoring Balloon 4. Debulking Techniques

1. Directional atherectomy(Outdated)2. Laser3. ROTA:undilatable ISR/calcified but DES-ISR (not been evaluated)

5. Vascular Brachytherapy is outdated by 2 DES studies1. The SISR (Sirolimus-Eluting Stent vs. Brachytherapy in Patients With Bare Metal In-Stent

Restenosis)2. TAXUS V ISR ( TAXUS Paclitaxel-Eluting Coronary Stent in the Treatment of In-Stent

Restenosis)

Prescription contd…..

6. Repeat Stenting for Patients With ISR1. BMS2. DES

7. DCB Angioplasty

PBA for ISR

• Favourable in “focal”• balloon-to-artery ratio of 1.1:1• “dog bone” effects should tackled with high pressure non compliant

balloon• “watermelon seeding” phenomenon should be attended• Edge dissections should be tackled• Limited experience in DES• DCB is preferred over PBA

cutting or scoring balloons

• The use of before DES or DCB is potentially valuable, and this approach is being assessed in ongoing randomized trials (e.g., ISAR-DESIRE 4 [Intracoronary Stenting and Angiographic Results: Optimizing Treatment of Drug Eluting Stent In-Stent Restenosis

“Onion-skin” phenomena

Stent in stent

BMS for ISR

• 6 Month result not better than PBA• Better for vessel >3mm• Better for stent edge dissection• Better for inadequate results after PBA• May be used for BMS ISR only for vessel more than 3 mm• Studies assessing the value of BMS in patients with DES-ISR are

lacking and unlikely to be undertaken

DES for BMS ISR :RIBS trials-DES>PBA better• Revolutionary for de novo• Off label for ISR• Late ISR is less • Edge dissection should be tackled• ISAR-DESIRE (Intracoronary Stenting or Angioplasty for Restenosis

Reduction–Drug-Eluting Stents for In-Stent Restenosis) trial was the first randomized study assessing the value of DES in patients with BMS-ISR) showed satisfactory results• SE is better than PE

DES for DES ISR

• Controversial • “onion-skin” phenomena• CABG is preferred

Drug coated balloon

• DCB in de novo lesions remains controversial• Effective in patients with both BMS-ISR and DES-ISR• RIBS V (Restenosis Intra-stent: Drug-eluting Balloon vs. Everelimus-

eluting Stent) trial:2nd generation DES is better in BMS ISR• ISAR-DESIRE 3 (Intracoronary Stenting and Angiographic Results: Drug

Eluting Stents for In-Stent Restenosis) :DCB is noninferior to paclitaxel eluting stent• RIBS IV (Restenosis Intra-stent of Drug-eluting Stents:Paclitaxel-eluting

Balloon vs Everolimus-eluting Stent)• ISARDESIRE-4 randomized trial:DCB+cutting/squared balloon vs DES

You read about role of statin for ISR

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