PCI in the patient with in stent restenosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Laura Nasrallah, M.D.;

Synonyms and Keywords: ISR

Overview[edit]

In-stent restenosis (ISR) is the most frequent late complication of stent implantation and occurs when there is a reoccurrence of stenosis in a lesion that was previously treated with a stent. In stent restenosis results from exaggerated neointimal formation. The lesion is primarily composed of smooth muscle cells and extracellular matrix. Intravascular ultrasound studies demonstrate that in stent restenosis is not due to extrinsic compression of the stent by scar tissue (i.e. there is not compression of the stent).

Epidemiology and Demographics[edit]

Although ISR has traditionally occurred in 30-40% of treated lesions, its incidence has been dramatically reduced by the development of drug-eluting stents.

Risk Factors[edit]

Patient-based Risk Factors[edit]

Lesion-based Risk Factors[edit]

Procedure Based Risk Factors[edit]

Treatment[edit]

The major goal of treating in-stent restenosis is to minimize the chance of recurrent restenosis. If a bare metal stent develops ISR, then a drug eluting stent should be placed. If ISR develops in a drug eluting stent, there is no data to suggest that a different type of drug eluting stent will prevent a recurrence (e.g. switching from sirolimus to paclitaxel). While use of a cutting balloon may improve acute angiographic results, there is no data to suggests that the use of a cutting balloon reduces the risk of a recurrence. Radiation treatment or brachytherapy was used in the past to treat ISR, but this procedure was associated with a higher rate of late stent thrombosis, and had fallen out of favor. ==2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)<ref name="pmid22070837">{{#invoke:Citation/CS1|citation |CitationClass=journal }}</ref>== ===Restenosis (DO NOT EDIT)<ref name="pmid22070837">{{#invoke:Citation/CS1|citation |CitationClass=journal }}</ref>===

Class I
"1. Patients who develop clinical restenosis after balloon angioplasty should be treated with bare metal stent (BMS) or drug eluting stent (DES) if anatomic factors are appropriate and if the patient is able to comply with and tolerate dual antiplatelet therapy (DAPT).<ref name="pmid9834304">{{#invoke:Citation/CS1|citation CitationClass=journal

}}</ref> (Level of Evidence: B)"

"2. Patients who develop clinical restenosis after bare metal stent (BMS) should be treated with drug eluting stent (DES) if anatomic factors are appropriate and the patient is able to comply with and tolerate dual antiplatelet therapy (DAPT).<ref name="pmid16531619">{{#invoke:Citation/CS1|citation CitationClass=journal

}}</ref><ref name="pmid17276188">{{#invoke:Citation/CS1|citation

CitationClass=journal

}}</ref><ref name="pmid15644543">{{#invoke:Citation/CS1|citation

CitationClass=journal

}}</ref>(Level of Evidence: A)"

Class IIa
"1. IVUS is reasonable to determine the mechanism of stent restenosis.<ref name="pmid21109112">{{#invoke:Citation/CS1|citation CitationClass=journal

}}</ref> (Level of Evidence: C)"

Class IIb
"1. Patients who develop clinical restenosis after drug eluting stent (DES) may be considered for repeat PCI with balloon angioplasty, bare metal stent (BMS), or drug eluting stent (DES) containing the same drug or an alternative antiproliferative drug if anatomic factors are appropriate and the patient is able to comply with and tolerate dual antiplatelet therapy (DAPT).<ref name="pmid21109112">{{#invoke:Citation/CS1|citation CitationClass=journal

}}</ref> (Level of Evidence: C)"

References[edit]

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