Upcoming events

Optimal treatment of recurrent restenosis lesions after drug-eluting stent implantation for in-stent restenosis lesions

Selected in EuroIntervention by S. Brugaletta

References

Authors

Kubo S, Kadota K, Otsuru S, Hasegawa D, Shigemoto Y, Habara S, Tada T, Tanaka H, Fuku Y, Katoh H, Goto T, Mitsudo K

Reference

EuroIntervention 2013;9:788-796

Published

November 2013

Link

Access the article

Aims

Although the outcomes of various treatments for in-stent restenosis (ISR) after drug-eluting stent (DES) implantation have been reported, the optimal treatment of recurrent ISR lesions after DES implantation for ISR lesions was unknown. This study compared the efficacy between DES implantation and balloon angioplasty (BA) for recurrent ISR lesions after DES implantation.

Methods and results

 From 2003 to 2010, DES were implanted in 1,101 ISR lesions, of which 148 recurrent ISR lesions (142 patients) were treated with BA (76 lesions, 72 patients) and DES implantation (72 lesions, 70 patients). Clinical outcomes were evaluated for major adverse cardiac events (MACE), including a composite of death, myocardial infarction, and target lesion revascularisation (TLR). Angiographic outcomes were evaluated by follow-up angiography at six to eight months after procedure. At angiographic follow-up (94.4% of all patients), the binary restenosis rate was significantly lower in DES implantation (25.0%) than in BA (64.4%, p<0.001), whereas late lumen loss was similar between DES implantation and BA (0.80±0.78 mm vs. 0.87±0.79 mm, p=0.60). The incidence of four-year MACE was significantly higher in BA (75.2%) than in DES implantation (45.8%, p<0.001), mainly because of the lower TLR rate in DES implantation (60.5% vs. 27.6%, p<0.001). Multivariate analysis revealed that BA is an independent predictor of TLR, followed by non-focal lesion, non-intravascular ultrasound guidance, and dyslipidaemia.

Conclusions

In the treatment of recurrent ISR lesions, DES implantation is markedly more effective with a lower incidence of TLR compared to BA.

 

My Comment

Background

For in-stent restenosis (ISR) lesions after bare metal stent implantation, DES implantation has been reported to have better clinical and angiographic outcomes than balloon angioplasty (BA) in some randomised trials. Although the best management for DES ISR lesions has not been established, repeat DES implantation has been reported to be superior to BA in several studies. However, Recurrent ISR after DES implantation for ISR lesions may still occurs, and it has become a clinically important problem, especially because there are no data available on the outcomes after PCI for recurrent ISR lesions after DES implantation for ISR lesions, because the circumstances requiring PCI for recurrent ISR lesions are infrequent. In this study, the clinical and angiographic outcomes between DES implantation and BA for recurrent ISR lesions after DES implantation for ISR lesions are compared.

Major findings

  • From 2003 to 2010, DESs were implanted in 1,101 ISR lesions, of which 148 recurrent ISR lesions (142 patients) were treated with BA (76 lesions, 72 patients) and DES implantation (72 lesions, 70 patients).
  • Clinical outcomes were evaluated for major adverse cardiac events (MACE), including a composite of death, myocardial infarction, and target lesion revascularisation (TLR). Angiographic outcomes were evaluated by follow-up angiography at six to eight months after procedure.
  • At angiographic follow-up (94.4% of all patients), the binary restenosis rate was significantly lower in DES implantation (25.0%) than in BA (64.4%, p<0.001), whereas late lumen loss was similar between DES implantation and BA (0.80±0.78 mm vs. 0.87±0.79 mm, p=0.60).
  • The incidence of four-year MACE was significantly higher in BA (75.2%) than in DES implantation (45.8%, p<0.001), mainly because of the lower TLR rate in DES implantation (60.5% vs. 27.6%, p<0.001). Multivariate analysis revealed that BA is an independent predictor of TLR, followed by non-focal lesion, non-intravascular ultrasound guidance, and dyslipidaemia.

Comments

This paper describes an interesting series of patients who experienced a re-ISR of a DES, which were not randomly treated by implantation of a DES or by dilatation by BA. Among the many messages that can be derived, I would like to focus on some. First is that it appears that intra-vascular imaging, such as IVUS, may help us in treating such ISR, identifying the underlying causes of restenosis (e.g. stent underexpansion, stent fracture, etc) and the corresponding most correct treatment. Second of note is that drug-eluting balloons were not taken into account in this series. With this regards, the data coming from RIBS-IV, which randomized DES-ISR to new DES or drug-eluting balloon will help us in treatment of ISR.

1 comment

  • Naeem Mengal 16 Dec 2013

    Expected results... What about data comparing DES and BMS in ISR.....