In stent restenosis

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In stent restenosis

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  • In-stent restenosis after percutaneous coronary intervention leads to repeat coronary revascularization, increased medical costs, and substantial increases in patient morbidity. In-stent restenosis is mainly caused by neointimal hyperplasia, which occurs in response to local arterial injury sustained during percutaneous coronary intervention leading to complex inflammatory and reparative processes. The efficacy of a coronary stent generally is highly dependent on its composition, including the stent platform and, in the case of drug-eluting stents, the active drug and the polymer in which it has been packaged (drug carrier). Interactions between the arterial tissue and the implanted stent are influenced by patient characteristics (e.g., risk profile, genetics, clinical presentation), type of stent, biologic factors (e.g., drug resistance, hypersensitivity), mechanical factors (e.g., stent underexpansion, nonuniform drug distribution, stent fracture), and technical factors (e.g., geographic miss, stent gap), forging the risk of restenosis. The temporal presentation, pattern, and response to treatment may differ between bare metal stent and drug-eluting stent restenosis. Drug-eluting stents are superior to bare metal stents because they reduce the risk of restenosis across all coronary lesions and patient subsets. The rates of restenosis differ among various drug-eluting stent platforms, in particular between first-generation and newer generation drug-eluting stents. Various clinical, angiographic, and procedural predictors of restenosis have been defined. Most cases of in-stent restenosis manifest with recurrent symptoms, including unstable angina and acute myocardial infarction. Coronary angiography is the “gold standard” for assessment of coronary restenosis severity. Computed tomography coronary angiography is a valuable imaging modality for assessing coronary artery disease, but its diagnostic value in the assessment of in-stent restenosis is limited in heavily calcified arteries, intermediate or small arteries or stents, thick stent struts, and regions of stent overlap. For bare metal stent restenosis, the treatment of choice is a drug-eluting stent. The optimal therapeutic approach for drug-eluting stent restenosis is unclear. Next-generation drug-eluting stents show promise in continuing to decrease the occurrence of restenosis after percutaneous coronary intervention through the use of novel antiproliferative drugs, improved stent platforms with better biocompatible or biodegradable polymers, or nonpolymeric drug-eluting stent surfaces or depots.
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In stent restenosis

  1. 1. In-Stent Restenosis Coronary artery disease
  2. 2. In stent restenosis • The biggest challenge in coronary angioplasty
  3. 3. 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
  4. 4. Restenosis rate POBA BMS DES 30-50% 20-30% <10%
  5. 5. What does happen after stenting ? Pathology BMS DES Imageology CAG OCT Diffuse Homogeneous, high signal band most common Focal Layered 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 months Rich Moderate Occasional 3–6 months Occasional Relatively infrequent, late Ongoing late loss out to 5 years Hypo cellular High Frequent Up to 4 yrs. Occasional Relatively frequent, accelerated course
  6. 6. Prescription 1. Conventional Balloon Angioplasty 2. Cutting Balloon: Prevents “watermelon seeding” 3. Scoring Balloon 4. Debulking Techniques 1. Directional atherectomy(Outdated) 2. Laser 3. ROTA:undilatable ISR/calcified but DES-ISR (not been evaluated) 5. Vascular Brachytherapy is outdated by 2 DES studies 1. 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)
  7. 7. Prescription contd….. 6. Repeat Stenting for Patients With ISR 1. BMS 2. DES 7. DCB Angioplasty
  8. 8. 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
  9. 9. 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
  10. 10. “Onion-skin” phenomena Stent in stent
  11. 11. 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
  12. 12. 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
  13. 13. DES for DES ISR • Controversial • “onion-skin” phenomena • CABG is preferred
  14. 14. 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
  15. 15. You read about role of statin for ISR Keep Learning because learning make you feel rich at bedside “Redefine success at the end of our lives, we’re all about the same amount of dust, so the question is how much joy have you brought into people’s lives and how have you made the world a better place?” Thank You

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