In stent restenosis

1. In-Stent Restenosis
Coronary artery disease

2. In stent restenosis
• The biggest challenge in coronary angioplasty

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. Restenosis rate
POBA BMS DES
30-50% 20-30% <10%

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. 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 Directional atherectomy(Outdated)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 Vascular Brachytherapy is outdated by 2 DES studies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. Prescription contd…..
6. Repeat Stenting for Patients With ISR
1. BMS
2. DES
7. DCB Angioplasty

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. 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. “Onion-skin” phenomena
Stent in stent

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. 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. DES for DES ISR
• Controversial
• “onion-skin” phenomena
• CABG is preferred

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. You read about role of statin for ISR
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