PCI complications: restenosis: Difference between revisions
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*The need for recurrent target [[lesion]] [[revascularization]] (TLR) increased with increasing ISR class, increasing from 19%, 35%, 50%, to 83% in classes I to IV, respectively (P <0.001)<ref name="pmid10545431">{{cite journal| author=Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF et al.| title=Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome. | journal=Circulation | year= 1999 | volume= 100 | issue= 18 | pages= 1872-8 | pmid=10545431 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10545431 }} </ref>. | *The need for recurrent target [[lesion]] [[revascularization]] (TLR) increased with increasing ISR class, increasing from 19%, 35%, 50%, to 83% in classes I to IV, respectively (P <0.001)<ref name="pmid10545431">{{cite journal| author=Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF et al.| title=Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome. | journal=Circulation | year= 1999 | volume= 100 | issue= 18 | pages= 1872-8 | pmid=10545431 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10545431 }} </ref>. | ||
*[[Restenosis]] after [[DES|drug eluting stent]] implantation is generally more focal than following [[bare metal stent]] placement<ref name="pmid15596568">{{cite journal| author=Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M et al.| title=Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries. | journal=Circulation | year= 2004 | volume= 110 | issue= 25 | pages= 3773-80 | pmid=15596568 | doi=10.1161/01.CIR.0000150331.14687.4B | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15596568 }} </ref><ref name="pmid12719283">{{cite journal| author=Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M et al.| title=Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation. | journal=Circulation | year= 2003 | volume= 107 | issue= 17 | pages= 2178-80 | pmid=12719283 | doi=10.1161/01.CIR.0000070592.04766.36 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12719283 }} </ref>, 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]]<ref name="pmid15596568">{{cite journal| author=Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M et al.| title=Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries. | journal=Circulation | year= 2004 | volume= 110 | issue= 25 | pages= 3773-80 | pmid=15596568 | doi=10.1161/01.CIR.0000150331.14687.4B | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15596568 }} </ref><ref name="pmid12719283">{{cite journal| author=Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M et al.| title=Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation. | journal=Circulation | year= 2003 | volume= 107 | issue= 17 | pages= 2178-80 | pmid=12719283 | doi=10.1161/01.CIR.0000070592.04766.36 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12719283 }} </ref><ref name="pmid12860901">{{cite journal| author=Lemos PA, Saia F, Ligthart JM, Arampatzis CA, Sianos G, Tanabe K et al.| title=Coronary restenosis after sirolimus-eluting stent implantation: morphological description and mechanistic analysis from a consecutive series of cases. | journal=Circulation | year= 2003 | volume= 108 | issue= 3 | pages= 257-60 | pmid=12860901 | doi=10.1161/01.CIR.0000083366.33686.11 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12860901 }} </ref>. | *[[Restenosis]] after [[DES|drug eluting stent]] implantation is generally more focal than following [[bare metal stent]] placement<ref name="pmid15596568">{{cite journal| author=Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M et al.| title=Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries. | journal=Circulation | year= 2004 | volume= 110 | issue= 25 | pages= 3773-80 | pmid=15596568 | doi=10.1161/01.CIR.0000150331.14687.4B | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15596568 }} </ref><ref name="pmid12719283">{{cite journal| author=Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M et al.| title=Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation. | journal=Circulation | year= 2003 | volume= 107 | issue= 17 | pages= 2178-80 | pmid=12719283 | doi=10.1161/01.CIR.0000070592.04766.36 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12719283 }} </ref>, 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]]<ref name="pmid15596568">{{cite journal| author=Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M et al.| title=Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries. | journal=Circulation | year= 2004 | volume= 110 | issue= 25 | pages= 3773-80 | pmid=15596568 | doi=10.1161/01.CIR.0000150331.14687.4B | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15596568 }} </ref><ref name="pmid12719283">{{cite journal| author=Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M et al.| title=Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation. | journal=Circulation | year= 2003 | volume= 107 | issue= 17 | pages= 2178-80 | pmid=12719283 | doi=10.1161/01.CIR.0000070592.04766.36 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12719283 }} </ref><ref name="pmid12860901">{{cite journal| author=Lemos PA, Saia F, Ligthart JM, Arampatzis CA, Sianos G, Tanabe K et al.| title=Coronary restenosis after sirolimus-eluting stent implantation: morphological description and mechanistic analysis from a consecutive series of cases. | journal=Circulation | year= 2003 | volume= 108 | issue= 3 | pages= 257-60 | pmid=12860901 | doi=10.1161/01.CIR.0000083366.33686.11 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12860901 }} </ref>. | ||
===2021 ACA Guidline Recommendations=== | |||
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| colspan="1" style="text-align:center; background:LightGreen"|Class 1 Recommendation, Level of Evidence: A<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950 }} </ref> | |||
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| bgcolor="LightGreen"|If another [[PCI]] is planned for a [[patient]] with clinical [[restenosis|in-stent restenosis (ISR)]], [[drug eluting stent]] ([[drug eluting stent|DES]]) is recommended with goal of outcome improvement (if [[anatomy|anatomic]] factors and [[dual antiplatelet therapy]] ([[Dual antiplatelet therapy|DAPT]]) compliance are considered). | |||
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| colspan="1" style="text-align:center; background:yellow"|Class 2a Recommendation, Level of Evidence: B-NR <ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950 }} </ref> | |||
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| bgcolor="yellow"|[[PCI]] can be chosen to reduce long-term [[ischemia|ischemic]] outcomes in [[diabetes|diabetic]] [[patients]] with [[multivessel coronary artery disease]] and poor [[surgery]] candidacy (only when there is an indication for [[revascularization]] and [[patient]] preferences are considered. | |||
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| colspan="1" style="text-align:center; background:Lightblue"|Class 2b Recommendation, Level of Evidence: B-R <ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950 }} </ref> | |||
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| bgcolor="lightblue"|[[PCI]] can decrease major adverse [[Circulatory system|cardiovascular]] outcomes as an alternative to [[CABG]] in [[diabetes|diabetic]] [[patients]] who have [[LAD]] [[stenosis]] and low to intermediate [[CAD]] complexity in other [[artery|arteries]]. | |||
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==References== | ==References== | ||
Revision as of 14:24, 3 July 2022
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Percutaneous coronary intervention Microchapters |
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PCI complications: restenosis On the Web |
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Risk calculators and risk factors for PCI complications: restenosis |
Editors-In-Chief: Alexandra Almonacid M.D.; Jeffrey J. Popma M.D. Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[1]
Restenosis
- Restenosis can occur in the implanted stent after performing PCI.[1]
- Factors such as stent type, chosen procedure, and patient-related factors are critical in the pathophysiology of stent thrombosis or restenosis.[2][3]
- It is necessary to evaluate the underlying cause of stent thrombosis with intracoronary imaging (IVUS and OCT) in order to plan the proper treatment.[2][4]
- 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 pathophysiology of restenosis can be anticipated based on the time period that restenosis occurs.[1]
- Early stent thrombosis is usually due to residual target-lesion thrombus, stent failure, or nonadherence to dual antiplatelet therapy.
- Late stent thrombosis is usually associated with inadequate neointimal coverage or incomplete healing.
Classification
Table 1. Mehran Classification System[5]
- Pattern I: Focal (≤ 10 mm in length) lesions
- Ia : Restenosis within the stent
- Ib : Restenosis at the edge of the stent
- Ic : Restenosis at the articulation or gap
- Id : Restenosis multifocal
- Pattern II: ISR >10 mm within the stent
- Pattern III: Includes ISR > 10 mm extending outside the stent
- Pattern IV: ISR totally occluded
Implications
- The need for recurrent target lesion revascularization (TLR) increased with increasing ISR class, increasing from 19%, 35%, 50%, to 83% in classes I to IV, respectively (P <0.001)[5].
- Restenosis after drug eluting stent implantation is generally more focal than following bare metal stent placement[6][7], 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[6][7][8].
2021 ACA Guidline Recommendations
| Class 1 Recommendation, Level of Evidence: A[1] |
| 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: B-NR [1] |
| PCI can be chosen to reduce long-term ischemic outcomes in diabetic patients with multivessel coronary artery disease and poor surgery candidacy (only when there is an indication for revascularization and patient preferences are considered. |
| Class 2b Recommendation, Level of Evidence: B-R [1] |
| PCI can decrease major adverse cardiovascular outcomes as an alternative to CABG in diabetic patients who have LAD stenosis and low to intermediate CAD complexity in other arteries. |
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check
|pmid=value (help). - ↑ 2.0 2.1 Dangas GD, Claessen BE, Caixeta A, Sanidas EA, Mintz GS, Mehran R (2010). "In-stent restenosis in the drug-eluting stent era". J Am Coll Cardiol. 56 (23): 1897–907. doi:10.1016/j.jacc.2010.07.028. PMID 21109112.
- ↑ Holmes DR, Kereiakes DJ, Garg S, Serruys PW, Dehmer GJ, Ellis SG; et al. (2010). "Stent thrombosis". J Am Coll Cardiol. 56 (17): 1357–65. doi:10.1016/j.jacc.2010.07.016. PMID 20946992.
- ↑ Fujii K, Mintz GS, Kobayashi Y, Carlier SG, Takebayashi H, Yasuda T; et al. (2004). "Contribution of stent underexpansion to recurrence after sirolimus-eluting stent implantation for in-stent restenosis". Circulation. 109 (9): 1085–8. doi:10.1161/01.CIR.0000121327.67756.19. PMID 14993129.
- ↑ 5.0 5.1 Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF; et al. (1999). "Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome". Circulation. 100 (18): 1872–8. PMID 10545431.
- ↑ 6.0 6.1 Popma JJ, Leon MB, Moses JW, Holmes DR, Cox N, Fitzpatrick M; et al. (2004). "Quantitative assessment of angiographic restenosis after sirolimus-eluting stent implantation in native coronary arteries". Circulation. 110 (25): 3773–80. doi:10.1161/01.CIR.0000150331.14687.4B. PMID 15596568.
- ↑ 7.0 7.1 Colombo A, Orlic D, Stankovic G, Corvaja N, Spanos V, Montorfano M; et al. (2003). "Preliminary observations regarding angiographic pattern of restenosis after rapamycin-eluting stent implantation". Circulation. 107 (17): 2178–80. doi:10.1161/01.CIR.0000070592.04766.36. PMID 12719283.
- ↑ Lemos PA, Saia F, Ligthart JM, Arampatzis CA, Sianos G, Tanabe K; et al. (2003). "Coronary restenosis after sirolimus-eluting stent implantation: morphological description and mechanistic analysis from a consecutive series of cases". Circulation. 108 (3): 257–60. doi:10.1161/01.CIR.0000083366.33686.11. PMID 12860901.