PCI complications: restenosis
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Restenosis can occur in the implanted stent after performing PCI. One of the classification systems categorized restenosis based on being multifocal or its location in the stent (such as at the edge of the stent, or at the articulation or gap. The main mechanism causing restenosis after stent implication is neointimal hyperplasia. Restenosis after drug eluting stent implantation is generally more focal than following bare metal stent placement. Risk of ISR is lowered after presentation of new generations stents such as DES compared to BMS and first-generation DES. Balloon angioplasty, drug eluting stents, drug-coated balloons, scoring or cutting balloons, and vascular brachytherapy are some of the common approaches that have been explored as the restenosis treatment. Among all the treatment options, drug eluting stents appear to provide the most benefit.
- Pattern I: Focal (≤ 10 mm in length) lesions
- Pattern II: ISR >10 mm within the stent
- Pattern III: Includes ISR > 10 mm extending outside the stent
- Pattern IV: ISR totally occluded
- Restenosis can occur in the implanted stent after performing PCI.
- The main mechanism causing restenosis after stent implication is neointimal hyperplasia.
- The pathophysiology of restenosis can be anticipated based on the time period that restenosis occurs.
- Restenosis after drug eluting stent implantation is generally more focal than following bare metal stent placement., and, with the sirolimus eluting stent, more is commonly at the margin of the stent due to balloon injury that is not covered with stent
Epidemiology and Demographics
- Risk of ISR is lowered after presentation of new generations stents such as DES compared to BMS and first-generation DES.
- Factors such as stent type, procedural characteristics, lesion location and patient-related factors are critical in the pathophysiology of stent thrombosis or restenosis.
- It is necessary to evaluate the underlying cause of stent thrombosis with intracoronary imaging (IVUS and OCT) in order to plan the proper treatment.
- In the setting of in-stent restenosis (ISR) after bare metal stent (BMS) implantation, the risk of recurrence can be predicted by the pattern of restenosis.
- The following approaches have been explored for restenosis treatments:
- Balloon angioplasty
- Drug eluting stents
- Drug-coated balloons
- Scoring or cutting balloons
- Vascular brachytherapy
- Overall, if chosen properly, vascular brachytherapy can bypass the need to implant another stent in patients who do have challenging circumstances.
- Atheroablative therapies
- CABG is recommended as an effective treatment among the following patients with in stents restenosis:
- When a patient experiences recurrent restenosis despite repeat PCI with DES
- When a patient experiences recurrent restenosis with diffuse in stents restenosis in large vessels
- When a patient experiences recurrent restenosis with a complex presentation such as CTO with multivessel disease
- CABG could be the preferred treatment in those with suitable anatomy
- CABG is recommended as an effective treatment among the following patients with in stents restenosis:
- The type of in stent restenosis is essential in deciding one treatment over the others and the ultimate decision should be made individualized.
2021 ACA Guidline Recommendations
|Class 1 Recommendation, Level of Evidence: A|
|If another PCI is planned for a patient with clinical in-stent restenosis (ISR), drug eluting stent (DES) is recommended with goal of outcome improvement (if anatomic factors and dual antiplatelet therapy (DAPT) compliance are considered).|
|Class 2a Recommendation, Level of Evidence: C-EO |
|If a patient with recurrent symptomatic diffuse in-stent restenosis (ISR) has a revascularization indication, planning CABG is preferred over repeat PCI to lower recurrent events.|
|Class 2b Recommendation, Level of Evidence: B-NR |
|In a patient with recurrent in-stent restenosis (ISR), brachytherapy could be helpful to improve symptoms|
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