OfficialreprintfromUpToDate

www.uptodate.com2016UpToDate

Intracoronarystentrestenosis
Authors
ThomasLevin,MD
DonaldCutlip,MD

SectionEditor
StephanWindecker,MD

DeputyEditor
GordonMSaperia,MD,FACC

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Feb2016.|Thistopiclastupdated:Oct20,2015.
INTRODUCTIONAlthoughintracoronarystentrestenosis(ISR)ismuchlesscommonwiththeuseofdrug
elutingstents(DES)thanwithbaremetalstents(BMS),thenumberofstentsbeingimplantedininterventional
practicemeansthatthetreatmentofISRremainsanimportantclinicalchallenge.
DEFINITIONSAfterasuccessfulprocedure,coronarystentscanfailtomaintainvesselpatencyduetoeither
restenosisorstentthrombosis.Restenosisisagradualrenarrowingofthestentedsegmentthatoccursmostly
between3to12monthsafterstentplacement.Itusuallypresentsasrecurrentangina,butcanpresentasacute
myocardialinfarctioninapproximately10percentofpatients.Itcanusuallybemanagedbyrepeatpercutaneous
revascularization.
Incontrast,stentthrombosisisanabruptthromboticocclusionofapreviouslywidelypatentstent.Itisa
catastrophiccomplicationthatpresentsassuddendeathorlargemyocardialinfarctioninmostpatients.Despite
successfulrepeatrevascularization,thesixmonthmortalityishigh.(See"Coronaryarterystentthrombosis:
Clinicalpresentationandmanagement"and"Coronaryarterystentthrombosis:Incidenceandriskfactors".)
Inthistopic,intracoronarystentrestenosis(ISR)andinstentrestenosisrefertothesameissue.
ThefollowingarewidelyagreedupondefinitionsrelatedtoISR(table1)[1]:
RestenosisAreductioninlumendiameterafterpercutaneouscoronaryinterventionduetoarterialdamage
andsubsequentneointimaltissueproliferation.
BinaryangiographicrestenosisA50percentluminalnarrowingatfollowupangiography.
ClinicalrestenosisThepresenceofbothbinaryangiographicrestenosisandclinicalsymptomsorsignsof
ischemia(eitheratrestorwithstress)ORrestenosiswitha70percentreductioninlumendiameterevenin
theabsenceofclinicalsymptomsorsigns.
INCIDENCEOFRESTENOSISTheincidenceofrestenosisdependsonthedefinitionofrestenosis(see
'Definitions'above),typeofstent,andthecomplexityofthelesion(s)stented.Restenosisratesareconsiderably
higherinmorecomplexlesionsubsets,suchassmallvessels,longlesions,andbifurcations.(See"Useof
intracoronarystentsforspecificcoronarylesions".)
BaremetalstentsApooledanalysisof6186patientsfromsixmajorclinicaltrialsassessedcurrent
generationbaremetalstents(BMS).Thefrequencyofclinicalrestenosiswasdefinedastargetlesionor
targetvesselrevascularization(TVR)beyond30days,death,ormyocardialinfarctioninthetargetvessel
territory[2].Atoneyear,targetlesionrevascularization(TLR)wasperformedin12percentandTVRin14.1
percent.Thesevaluesweremorethantwothirdshigherthanthoseatsixmonths(6.9and8percent).
Clinicallyrelevantrestenosisoccurredinonlyaboutonehalfofpatientswithangiographicrestenosis(defined
as50percentdiameterstenosis).Thiswasmostlyamatterofdegree,since50to70percentangiographic
stenosisisunlikelytocausesymptoms.TheincidenceofTLRwasmuchhigherwithmorethan70percent
diameterstenosis(73versus26percentforlessthan60percentdiameterstenosis).Thepredictorsofboth
clinicalandangiographicrestenosiswerethesame(smallerposttreatmentlumendiameter,stentlength,and
diabetes).

ClinicalrestenosiswithsecondgenerationBMSisarelativelyearlyevent,mostoftenbecomingclinically
evidentwithinthefirst6to12monthsaftertheprocedure[3].Afteroneyear,recurrentischemiaismore
likelytobeduetoneworprogressivediseaseatanothersiteratherthanrestenosis.Themagnitudeofthis
differencewasillustratedinareviewof1228patientswhowerefollowedforfiveyears[3].Afterthefirst
year,theannualhazardratewas1.7percentfortargetlesioneventscomparedwith6.3percentfornontarget
lesionevents.
DrugelutingstentsTherateofintracoronarystentrestenosis(ISR)hasbeenreportedbetween3to20
percent,dependingonwhichdrugelutingstent(DES)isevaluated,thedurationoffollowup,andthe
complexityofthelesionsinwhichthestentswereplaced[1].Thefollowingthreestudiesprovide
representativeoutcomes:
ForfirstgenerationDES(sirolimusorpaclitaxelDES),therateofrestenosisisbetween13and16
percentatfiveyears[4,5].(See"Comparisonofdrugelutingintracoronarystents",sectionon'Sirolimus
andpaclitaxelstents'.)
Inapooledanalysisofmultiplestudiescomparingeverolimuselutingwithzotarolimuselutingstents,
theratesofTVRatuptofiveyearsoffollowupwere6.3and5.0percent,respectively[6].(See
"Comparisonofdrugelutingintracoronarystents",sectionon'Zotarolimuselutingstents'.)
MultipletrialshavedemonstratedthatbothfirstgenerationsirolimusandpaclitaxelDESandsecondgeneration
everolimusandzotarolimusDESmarkedlyreducedtheincidenceofISRandtherateofTLRbyabout75percent
comparedwithBMS.Thedatasupportingthisconclusionarediscussedindetailelsewhere.(See"Drugeluting
comparedtobaremetalintracoronarystents"and"Comparisonofdrugelutingintracoronarystents".)
PATHOGENESISReductioninlumendiameterfollowingstentimplantationistheresultofarterialdamagewith
subsequentneointimaltissueproliferation.Typically,neointimalproliferationisdistributeduniformlyalongthe
lengthofthestent[79],butmayalsoberelativelyfocal.Theneointimalproliferationoccursinassociationwith
macrophageaccumulationandextensiveneovascularization,suggestingarolefororganizationofmuralthrombus
[10].
Consistentwiththishypothesisarethepathologicfindingsin55stentsin35coronaryarteriesfrompatientswho
died,hadrepeatcoronaryarterybypassgraft(CABG)surgery,orunderwenttransplantation.Themeandurationof
stentplacementwas39days[11].Thefollowingabnormalitieswerenoted:
Fibrin,platelets,andneutrophils,indicatingthrombusformationandacuteinflammation,havebeen
demonstratedatstentstrutsevaluated11daysafterplacement.Inflammationwasmorepronouncedin
strutsthatwereembeddedinalipidcoreandthoseincontactwithdamagedmedia.
Stentsevaluatedatalatertimeshowedneointimalgrowththatincreasedastheratioofstentareato
referencelumenareaincreased.Neointimalthicknesswasgreaterforstrutsassociatedwithmedialdamage
thanforthoseincontactwithplaque.Overtime,extracellularmatrixaccumulationmayplayagreaterrole
thancellproliferationinneointimalthickening[12].
Althoughthereisanincreaseinneointimaltissuewithsubsequentreductionintheminimalluminaldiameterduring
thefirstsixmonthsafterstentplacement,theremaybenofurtherreductioninluminaldiameterorevenregression
atoneyearandafurtherincreaseindiameteratlatertimepoints[1315].Serialangiographyandangioscopyfound
thefollowingsequenceofchanges[14].Therewasinitialthickeningoftheneointimathatbecamenontransparent
atsixmonths.Thereafter,theneointimabecamethinandtransparent(ie,themajorityofthestentwasvisible).
Thiscorrelatedwithanincreaseintheluminaldiameter.
MechanismsMechanismstoexplaintheobservationsofinflammation,muralthrombus,andneointimaltissue
growthinclude[1]:
Biologicfactors,suchasresistancetothedrugcomponentofstents

 Hypersensitivity
Mechanicalfactorssuchasstentunderexpansionorstentfracture
Technicalfactorssuchasbarotraumaoutsidethestentedsegment
PatternsofrestenosisPatternsofintracoronarystentrestenosis(ISR)havebeendescribedasfocalor
diffuse.However,inordertofurtherclassifythetypesofrestenosis,anangiographicclassificationwasdeveloped
inastudyof288ISRlesionsin245patients[16]:
PatternIdescribesafocal(<10mminlength)lesionandwasfoundin42percentofpatients.Subsequent
targetlesionrevascularization(TLR)wasperformedin19percentofpatients.
PatternIIdescribesISR>10mmwithinthestentandwaspresentin21percentofpatients35percent
requiredTLR.
PatternIIIdescribesISR>10mmextendingoutsidethestentTLRperformedin50percentofpatients.
PatternIVdescribesatotallyoccludedstent,whichwasfoundin7percentofpatients83percentunderwent
TLR.
PREDICTORSOFRESTENOSISINBMSInareviewof1084patientswhounderwentfollowupangiography
sixmonthsafterbaremetalstent(BMS)placement,theincidenceofrestenosisisrelatedtothenumberofrisk
factorspresent(aslowas16percentintheabsenceofanyriskfactors[diabetes,multiplestents,andminimal
luminaldiameterafterstenting<3mm])[17],andashighas59percentwhenatleastthreefactorswerepresent
(figure1)[18].
AngiographicfactorsAnumberofangiographicriskfactorshavebeenidentifiedforstentrestenosis,mostly
withBMS[2,1827].(See"Useofintracoronarystentsforspecificcoronarylesions".)
Restenotictargetlesion[27].
Longerstentedstenosislengthandstentlength[21,28,29].
Smallervesselsize.
Ostiallesionlocation.
Preinterventionallesionsiteplaqueburden(plaque/totalarterialarea)andamountofresidualplaqueburden
afterstentimplantation.
Longitudinalstraighteningeffectandpoststentchangesinvesselangulation9.1degrees[26].
Minimallumendiameter<3mmattheendoftheprocedure[24].
Minimumstentareaandinstentdiameter[29].
Latelumenloss,whichisduetoinstentneointimalhyperplasia,isdefinedasthedifferencebetweenthe
minimumlumendiameterimmediatelyafterstentingandtheminimumlumendiameteratsixtoeightmonth
angiographicfollowup.ItisanimportantpredictoroftheriskofclinicalrestenosiswithbothBMSanddrug
elutingstents(DES)andappearstobemorereliablethanbinaryangiographicrestenosis(>50percent
diameterstenosisatfollowup)[3032].
Themorphologyofthecoronarylesionalsomayhavepredictivevalue(table2)[33,34]:
TypeAlesionsHighsuccessandlowrestenosisrate.
TypeBlesionsIntermediatesuccessandmoderateriskofrestenosisthishasbeenfurthermodified
totypeB1(oneadversetypeBcharacteristic)andtypeB2(morethanonetypeBcharacteristic).
TypeClesionsLowsuccessandhighriskofrestenosis.

ClinicalfactorsStudiesofBMSidentifiedanumberofindependentclinicalpredictorsofstentrestenosisand
theneedfortargetvesselrevascularization(TVR),includingfemalesex,diabetes,hypertension,weightandbody
massindex,multivesseldisease,andtheuseofmultiplestents[2,1820,27].
Cigarettesmokersrequiretargetlesionrevascularization(TLR)significantlylessfrequentlythannonsmokers(6.6
versus10.1percentinonestudy)[35,36].Despitethisdifferenceinclinicalrestenosis,theangiographicrestenosis
ratedoesnotdifferbetweenthegroups[35,37],andtheratesofsubsequentdeathandmyocardialinfarctionare
significantlyhigherforsmokers[36].Explanationsforthisparadoxincludeareducedsensitivitytorestenosisora
greaterreluctancetoseekmedicalattentionforrecurrentanginainsmokers[35].
Acontactallergytometalcompounds,particularlynickel,releasedfromstainlesssteelstentsmaycontributeto
thedevelopmentofstentrestenosis,althoughtheevidenceforthisislimited.Studiesevaluatingtheassociation
betweenmetalallergyandstentrestenosisarereviewedseparately.(See"Nickelhypersensitivityandcoronary
arterystents".)
StrutthicknessStrutthicknessmayinfluencethedevelopmentofstentrestenosis[3840].Thiswasevaluated
intheISARSTEREOtrialinwhich651patientswithlesionsinvessels>2.8mmindiameterwererandomly
assignedtoaBMSwithathin(50micrometers)orthick(140micrometers)strut[38].Atsixmonths,thethinstrut
grouphadasignificantlylowerincidenceofangiographicrestenosis(15versus26percentforthethickstrut,
relativerisk[RR]0.58)andalesserlikelihoodofreinterventionforclinicalrestenosis(8.6versus13.8percent,RR
0.62).
ThecompanionISARSTEREO2trialcomparedthesamestentgeometry,fabricatedwitheitherthinorthick(140
micrometers)strutsin611patients[39].Proceduralsuccesswas99percentinbothgroups,butdevicesuccess
waslowerwiththethinstent(87versus99percentwiththethickstent).Thethinstentwasassociatedwith
significantreductionsinangiographicrestenosisatsixmonths(18versus31percent)andTVRatoneyear(12
versus22percent).TherewasnodifferenceinthecombinedendpointofdeathorMIatoneyear.
Thesignificanceoftheindependenteffectofstrutthicknessonrestenosismustawaitmoredetailedanalysesfrom
theseandotherstudies.
MechanicalproblemsTechnicalproblemsassociatedwithstentdeploymentcontributetorestenosisina
significantnumberofpatients.Inareviewof1090patientswithrestenosisinBMSwhounderwentintravascular
ultrasound(IVUS),mechanicalcomplicationswereconsideredtocontributein4.5percent,whileanadditional20
percenthadstentunderexpansionasacontributingfactor[41].Thesefindingshighlighttheneedforoptimal
stenting,aswiththeuseofhighpressureballoondilationwithorwithoutIVUS.(See"Generalprinciplesoftheuse
ofintracoronarystents",sectionon'Optimalstenting'.)
StentingofmultiplelesionsInpatientswhoundergostentplacementinmultiplelesions,therestenosisrate
appearstobehigherforalesionwhenacompanionlesiondevelopsrestenosis.Onestudyevaluated1244
patientswhounderwentstentplacementin1734lesions.Therestenosisrateforsingle,double,or3lesion
stentingwas24,29,and34percent,respectively,onaperlesionbasisand24,44,and63percent,respectively,
onaperpatientbasis[42].Theriskofalesiondevelopingrestenosiswas2.5timeshigherifacompanionlesion
hadrestenosis,aneffectthatwasindependentofallotherclinicalfactorsassociatedwithrestenosis.(See"Use
ofintracoronarystentsforspecificcoronarylesions",sectionon'Multivesselrevascularization'.)
PREDICTORSINDESAlthoughrestenosisissignificantlylesscommonwithdrugelutingstents(DES)than
baremetalstents(BMS),itstilloccursataratebetween3and20percentdependingonthedurationoffollowup
andthecomplexityoftheinitiallesion.(See'Incidenceofrestenosis'above.)
ClinicalpredictorsappeartoplayalessrelevantroleinrestenosiswithDEScomparedwithBMS[43].Predictors
oftargetlesionrevascularization(TLR)(anapproximationofrestenosis)inpatientsreceivingzotarolimusor
everolimuselutingstentswereevaluatedintheRESOLUTEAllComerstrial[44].Atfouryears,majorpredictors
ofTLR,whichoccurredin8.6percentofpatients,includedinsulintreateddiabetes(oddsratio[OR]1.97),

treatmentofsaphenousveingrafts(OR2.28),ostiallesions(OR2.17),orintracoronarystentrestenosis(ISR)(OR
2.24).(See"Comparisonofdrugelutingintracoronarystents",sectionon'Everolimusversuszotarolimuseluting
stents'.)
Inanangiographicfollowupstudyof238patientswhounderwentsirolimuselutingstentplacementincomplex
lesions,thefollowingcharacteristicswereidentifiedasindependentmultivariatepredictorsofangiographic
restenosis:treatmentofISR(OR4.16)ostiallocation(OR4.84)diabetes(OR2.63)totalstentedlength(per10
mmincrease,OR1.42)referencediameter(per1mmincrease,OR0.46)andleftanteriordescendingartery(OR
0.30)[22].
Inanotherangiographicfollowupstudyof1845patientswhounderwentimplantationofeithersirolimuseluting
stentsorpaclitaxelelutingstents,thefollowingwerefoundtobeindependentmultivariatepredictorsof
angiographicrestenosis:vesselsize(per0.5mmdecrease,OR1.74,95%CI1.312.32)finaldiameterstenosis
(per5percentincrease,OR1.30,95%CI1.151.47)andsirolimuselutingstentscomparedwithpaclitaxeleluting
stent(0.60,95%CI0.440.81)[43].
CLINICALPRESENTATIONANDDIAGNOSISOFISRForpatientswithpriorplacementofanintracoronary
stent,recurrentsymptomsofmyocardialischemia,usuallyinastablepattern,maybeduetorestenosis,
incompleterevascularizationatthetimeoftheinitialstentplacement,ordiseaseprogressionelsewhere.The
diagnosisofintracoronarystentrestenosis(ISR)isconfirmedbycoronaryangiography,usuallyperformedasa
preludetorepeatcatheterbasedtherapyinthesamesitting.(See"Anginapectoris:Chestpaincausedby
myocardialischemia",sectionon'Clinicalfeatures'.)
Anappreciableproportionofpatientswithbaremetalstents(BMS)canpresentwithanacutecoronarysyndrome
(3to20percent)[4547].Asimilarlyhighfrequencyofacutecoronarysyndrome(mostlyunstableangina)hasbeen
notedwithrestenosisindrugelutingstents(DES).IntwosmallreportsofpatientswithDESrestenosis,27and50
percentpresentedwithadiagnosisofunstableanginapectorisand5and11percentpresentedwithmyocardial
infarction[48,49].(See"Coronaryarterystentthrombosis:Incidenceandriskfactors".)
MANAGEMENTTheindicationsforcoronaryangiographyandrepeatrevascularizationinpatientswithprior
stentingandstableanginaaresimilartothoseforpatientswithoutpriorintervention.(See"Stableischemicheart
disease:Indicationsforrevascularization",sectionon'IndicationsforPCI'.)
Mostpatientswhoarediagnosedwithintracoronarystentrestenosis(ISR)andwhoundergorevascularizationwill
undergorepeatstenting.TheroleofsurgeryinthetreatmentofISRisuncertain.Revascularizationwithcoronary
arterybypassgraft(CABG)surgeryshouldbeconsideredinpatientswhoaredeemedtonotbecandidatesfor
percutaneousinterventionorwhomeettheestablishedcriteriaforitsuseinpatientswithstableangina.Patient
preferenceplaysanimportantroleindecisionmakingatthetimeofsymptomaticISR.Therelativebenefitsand
risksofmedical,percutaneous,andsurgicaltreatmentsneedtobediscussed.Inparticular,theneedforlongterm
dualantiplatelettherapy(aspirinandplateletP2Y12receptorblocker)withDESmustbeunderstoodbythepatient.
(See"Revascularizationinpatientswithstablecoronaryarterydisease:Coronaryarterybypassgraftsurgery
versuspercutaneouscoronaryintervention",sectionon'Twoandthreevesseldisease'.)
WeplaceanewergenerationDESwithintheoriginalstentinmostcases.Percutaneouscoronaryintervention
usingothertechniquessuchasplainoldballoonangioplastyplacementofaBMS,orintracoronaryradiation,is
performedlessoften.Theuseofdrugelutingballoon(DEB)angioplasty,ratherthanplacementofanewer
generationDESisreasonableinthoselocationswherethedeviceisavailable.
Specializedrevascularizationdevices,suchasrotationalordirectionalatherectomyandlaserangioplastyareused
infrequentlytotreatISR.Thesetoolsarediscussedseparately.(See"Specializedrevascularizationdevicesinthe
managementofcoronaryheartdisease"and"Coronaryarterybypassgraftsurgery:Preventionandmanagement
ofveingraftstenosis",sectionon'Atherectomy'.)
OurrecommendationsforantiplatelettherapyafterISRaresimilartothebroadpopulationofpatientswhoreceive

intracoronarystents.(See"Longtermantiplatelettherapyaftercoronaryarterystentinginstablepatients",section
on'Summaryandrecommendations'.)
RoleofIVUSWeperformintravascularultrasound(IVUS)oftheISRregioninmostpatients.IVUSallowsfor
thedetectionofunderexpansionoftheoriginalstent.Ifunderexpansionisfound,highpressureballoondilationis
performedpriortotheplacementofasecondstent.(See"Intravascularultrasound,opticalcoherencetomography,
andangioscopyofcoronarycirculation".)
ChoiceofdevicePlacementofanewergenerationdrugelutingstent(DES),andinparticularaneverolimus
elutingstent,isthepreferredtreatmentforpatientswithISR,irrespectiveofwhethertheoriginalstentwasbare
metalordrugeluting.Thevariouspotentialpercutaneouscoronaryinterventional(PCI)techniquesofplainold
balloonangioplasty,baremetalstenting,oroldergenerationstenting,newergenerationstenting(table3),
atherectomy,brachytherapy,andDEBs,havebeencomparedinmultiplestudies[22,5068].
ThesestudieshaveestablishedthesuperiorityofnewergenerationDEStoallotherPCIdevices.A2015well
performednetworkmetaanalysisevaluated27trials(n=5923)whichcomparedeverolimuselutingstentwithone
ormoreoftheotherdevicesandnotedthefollowing[69]:
Theprimaryendpointofpercentdiameterstenosisatangiographicfollowupoccurredlessoftenwith
everolimuselutingstents:9percent(95%CI15.8to2.2)comparedwithdrugcoatedballoon9.4percent
(95%CI17.4to1.4percent)comparedwithsirolimuselutingstents10.2percent(95%CI18.4to2
percent)comparedwithpaclitaxelelutingstents19.2(95%CI28.2to10.4percent)comparedwith
vascularbrachytherapy23.4percent(95%CI36.2to10.8percent)comparedwithBMS24.2percent
(95%CI32.2to16.4percent)comparedwithballoonangioplastyand31.8percent(95%CI44.8to18.6
percent)comparedwitharotablator.
PCIwitheverolimuselutingstentswasassociatedwithalowerriskoftargetlesionrevascularization(TLR)
thanallotherstrategies.
DespitetheapparentsuperiorityoftheeverolimuselutingstentscomparedwithaDEB,webelieveithassome
role,particularlyasthenetworkmetaanalysisdiscussedabovesuggests,thatitmaybesuperiortootherdevices.
Forexample,patientswhoarenotgoodcandidatesforlongtermdualantiplatelettherapy,thoseinwhomthereisa
concernabouthavingtoomuchmetal(eg,threeconcentricstents)inonelocation,andwhencompromiseofflow
inasidebranchisaconcernmaybereasonablecandidatesforaDEB.
Occasionally,weuseascoring(cutting)balloonpriortostentingtoincreasethelikelihoodofachievinganoptimal
finalinternalluminaldiameter.(See"Specializedrevascularizationdevicesinthemanagementofcoronaryheart
disease",sectionon'Cuttingballoonangioplasty'.)
RECOMMENDATIONSOFOTHERSThe2014EuropeanSocietyofCardiology/EuropeanAssociationfor
CardioThoracicSurgeryguidelineonmyocardialrevascularizationrecommendseitherdrugelutingstent(DES)or
drugcoatedballoonsforthetreatmentofintracoronarystentrestenosis(ISR)(baremetalstents[BMS]orDES)
[70].
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)

 BeyondtheBasicstopics(see"Patientinformation:Anginatreatmentmedicalversusinterventional
therapy(BeyondtheBasics)"and"Patientinformation:Stentingfortheheart(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Indicationsforrepeatrevascularizationinpatientswithintracoronarystentrestenosis(ISR)aresimilarto
thoseforpatientswithoutpriorstentplacement.Weperformcoronaryarteryrevascularizationinmost
patientsdiagnosedwithISRratherthanacontinuationofmedicaltherapyinanattempttocontrolsymptoms.
WeperformpercutaneouscoronaryinterventioninmostpatientswithISRratherthancoronaryarterybypass
grafting(CABG).(See'Management'above.)
Priortopercutaneouscoronaryinterventionforrestenosis,weperformintravascularultrasound(IVUS)in
mostcasestodetermineiftheoriginalstentisadequatelyexpandedandtofurtherevaluatethesizeofthe
referencevessel.(See'RoleofIVUS'above.)
If,withIVUS,theoriginalstentappearsunderexpanded,weusehighpressureballoondilatation,withan
appropriatelysizednoncompliantballoon(originalstentsize)andthenplaceanadditionalstent.Iftheoriginal
stentisnotunderexpanded,weplaceanappropriatelysizedstentwithouttheuseofahighpressureballoon.
(See'Management'above.)
Ourrecommendationsforantiplatelettherapyaresimilartothebroadpopulationofpatientswhoreceive
intracoronarystents.(See"Longtermantiplatelettherapyaftercoronaryarterystentinginstablepatients",
sectionon'Summaryandrecommendations'.)
InpatientswithISR(baremetalstents[BMS]ordrugelutingstents[DES])whorequirerepeat
revascularization,werecommendstentingusingacurrentgenerationDES,andinparticular,aneverolimus
elutingstent,ratherthantreatingwithaBMS,balloonangioplasty,andintracoronaryradiation(Grade1B)
[71].Theuseofadrugelutingballoonisalsoareasonableoptionwhereavailable.(See'Management'
above.)
Inpatientswhoareunlikelytocomplywitharecommendationforlongtermdualantiplatelettherapy,
alternativesincludecontinuationofmedicaltherapy,balloonangioplastyorrepeatBMS,orCABGsurgery.
(See'Management'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic1587Version25.0

GRAPHICS
Definitionsandclassificationofstentrestenosis
Angiographicrestenosisandclassification
Diameterstenosis50%
TypeIfocal:10mminlength
IAarticulationorgap
IBmargin
ICfocalbody
IDmultifocal

Type2diffuse:>10mmintrastent
Type3proliferative:>10mmextendingbeyondthestentmargins
Type4totalocclusion:RestenoticlesionswithTIMIflowgradeof0

Clinicalrestenosis:Assessedobjectivelyasrequirementforischemia
drivenrepeatrevascularization
Diameterstenosis50%andoneofthefollowing:
Positivehistoryofrecurrentanginapectoris,presumablyrelatedtotargetvessel
Objectivesignsofischemiaatrest(ECGchanges)orduringexercisetest(orequivalent),
presumablyrelatedtotargetvessel
Abnormalresultsofanyinvasivefunctionaldiagnostictest(eg,coronaryflowvelocity

reserve,FFR<0.80)IVUSminimumcrosssectionalarea<4mm 2(and<6.0mm 2for

leftmainstem)hasbeenfoundtocorrelatewithabnormalFFRandneedforsubsequent
TLR [13]
TLRwithdiameterstenosis70%eveninabsenceoftheaboveischemicsignsor
symptoms
TIMI:thrombolysisinmyocardialinfarctionECG:electrocardiographyFFR:fractionalflowreserveIVUS:
intravascularultrasoundTLR:targetlesionrevascularization.
References:
1.AbizaidAS,MintzGS,MehranR,etal.Longtermfollowupafterpercutaneoustransluminal
coronaryangioplastywasnotperformedbasedonintravascularultrasoundfindings:importanceof
lumendimensions.Circulation1999100:256.
2.JastiV,IvanE,YalamanchiliV,etal.Correlationsbetweenfractionalflowreserveand
intravascularultrasoundinpatientswithanambiguousleftmaincoronaryarterystenosis.
Circulation2004110:2831.
3.DoiH,MaeharaA,MintzGS,etal.Impactofinstentminimallumenareaat9monthspoststent
implantationon3yeartargetlesionrevascularizationfreesurvival:aserialintravascular
ultrasoundanalysisfromtheTAXUSIV,V,andVItrials.CircCardiovascInterv20081:111.
Originaltablemodifiedforthispublication.From:DangasG,ClaessenB,CaixetaA,etal.InStent
RestenosisintheDrugElutingStentEra.JAmCollCard201056:1897.Tableusedwiththepermission
ofElsevierInc.Allrightsreserved.

Graphic56696Version5.0

Incidenceofrestenosisincreaseswiththenumberof
riskfactors

Therateofstentrestenosisandtheneedfortargetlesionrevascularization
(TLR)increasesasmoreofthestrongestriskfactorsarepresent.Risk
factorsincludediabetes,multiplesstents,andminimumluminaldiameter
afterstenting<3mm.
DatafromKastratiA,SchomigA,EleziS,etal.JAmCollCardiol199730:1428.
Graphic78635Version2.0

Lesionspecificcharacteristicsandoutcomeafterballoon
angioplasty
TypeAlesions:Highsuccess(>85%)lowrisk
Discrete,<10mminlength
Concentric
Readilyaccessible
Nonangulatedsegment,<45degrees
Smoothcontour
Littleornocalcification
Lessthantotallyocclusive
Notostialinlocation
Nomajorbranchinvolvement
Absenceofthrombus

TypeBlesions:Moderatesuccess(60to85%)moderaterisk(TypeB1:
OnetypeBcharacteristicTypeB2:MorethanonetypeBcharacteristic)
Tubular,10to20mminlength
Eccentric
Moderatetortuosityofproximalsegment
Moderatelyangulatedsegment(>45degrees,<90degrees)
Irregularcontour
Moderatetoheavycalcification
Totalocclusionslessthanthreemonthsoldand/orbridgingcollaterals
Ostialinlocation
Bifurcationlesionsrequiringdoubleguidewires
Somethrombuspresent

TypeClesions:Lowsuccess(<60%)highrisk
Diffuse,>20mminlength
Excessivetortuosityofproximalsegment
Extremelyangulatedsegments>90degrees
Totalocclusionmorethanthreemonthsold
Inabilitytoprotectmajorsidebranches
Degeneratedveingraftswithfriablelesions
*Althoughtheriskofabruptvesselclosureismoderate,incertaininstancesthelikelihoodofamajor
complicationmaybelowwithdilationoftotalocclusionslessthanthreemonthsoldorwhenabundant
collateralchannelssupplythedistalvessel.

FromRyanTO,AxonDP,GunnarRM,etal.JAmCollCardiol198812:529.
Graphic80401Version4.0

CoronaryarterystentsapprovedintheUnitedStates

Name

Manufacturer

Stent
material

Polymer
(thickness)
anddrug
elution
kinetics

Drug

Baremetalstents
Vision

AbbottVascular

Cobaltchromium

VeriFLEX

BostonScientific

Stainlesssteel

REBEL

BostonScientific

Platinum
chromium

Integrity

Medtronic

Cobaltchromium

Paclitaxel

SIBBS16
micrometers

Durablepolymerdrugelutingstentscurrentlyinuse
TaxusIon

BostonScientific

Platinum
chromium

approximately
10%overtwo
weeks
Xience(V,

AbbottVascular

Cobaltchromium

Everolimus

Prime,
Xpedition)

PMBA/PVDFHFP
7.6micrometers
80%withinfour
weeks

Promus
(Element,
Premier)

BostonScientific

Platinum
chromium

Everolimus

PMBA/PVDFHFP
7.6micrometers
80%withinfour
weeks

Endeavor

Medtronic

Cobaltchromium

Zotarolimus

Phosphoryl
Choline5.3
micrometers
95%withintwo
weeks

Resolute

Medtronic

Cobaltchromium

Zotarolimus

Biolynx*5.6
micrometers
85%withineight
weeks

Bioabsorbablepolymerdrugelutingstentscurrentlyinuse
SYNERGY

BostonScientific

Platinum
chromium

Everolimus

Polylactideco
glycide4
micrometers
>95%withintwo
weeks

Previouslyapproveddrugelutingstents

Cypher

Cordis/J&J

Stainlesssteel

Sirolimus

PEVA/PMBA12.6
micrometers
>80%
withinfourweeks

Taxus

BostonScientific

Stainlesssteel

Paclitaxel

SIBBS
16micrometers
approximately
10%overtwo
weeks

Promus

BostonScientific

Cobaltchromium

Everolimus

PMBA/PVDFHFP
7.6micrometers
80%withinfour
weeks

SIBBS:poly(styrenebisobutylenebstyrene)PVDFHFP:poly(vinylidenefluoridehexafluoropropylene)
PEVA:polyethylenecovinylacetatePBMA:poly(nbutylmethacrylate).
*Proprietarypolymer.
Biodegradablepolymer(>90%ofpolymerabsorbedby120days)
CourtesyofJDawnAbbott,MD.
Graphic65603Version12.0