Treatment of in-stent restenosis with high speed rotational atherectomy and IVUS guidance in small <3.0 mm vessels

Long-term outcome of patients with proximal left anterior descending coronary artery in-stent restenosis treated with rotational atherectomy

Once a first interventional procedure has failed, patients with proximal left anterior descending in-stent restenosis are frequently sent for surgical revascularization. Data on long-term outcome in selected patients with proximal left anterior descending in-stent restenosis treated with RA are lacking. The study's objective was to evaluate the long-term outcome of patients with proximal left anterior descending artery in-stent restenosis treated with rotational atherectomy. The study population is constituted by 42 patients with proximal left anterior descending in-stent restenosis treated with rotational atherectomy. Patients were followed up for 2.1 +/- 0.9 years (range, 6--54). Restenosis length was 16.5 +/- 9.2 mm, and restenosis was diffuse (> 10 mm in length) in 30 (71.4%). The rotational atherectomy procedure was guided by intravascular ultrasound in 18 patients (42.9%). Maximum burr/artery ratio was > 0.7 in 24 (57.1%) patients. One patient suffered a periprocedural non--Q-wave infarction, but no deaths, Q-wave infarction, or new target vessel revascularization occurred during hospitalization. There were no deaths or myocardial infarctions after discharge. Sixteen patients (38.1%) needed a new revascularization, but only five (11.9%) underwent coronary bypass grafting at the end of the follow-up (2.1 +/- 0.9 years). The rate of surgical revascularization at 6 months, 1 year, and 3 years was 4.8%, 7.4%, and 18.4%, respectively. The rate of new target vessel revascularization at 6 months, 1 year, and 3 years was 16.7%, 36.5%, and 40.5%, respectively. Patients with < or = 5 months since stent implantation had a significantly higher rate of new target vessel revascularization. Patients with proximal left anterior descending in-stent restenosis may be safely treated with rotational atherectomy. This strategy is associated with a very good long-term outcome, with few patients undergoing surgical revascularization.

Repeat intervention for in-stent restenosis: re-expansion of the initial stent is a predictor of recurrence of restenosis

BACKGROUND

In-stent restenosis has become a significant clinical problem as use of stents has increased. The optimal strategy for dealing with in-stent restenosis needs to be evaluated.

OBJECTIVE

To compare the acute and late results of interventions for in-stent restenosis according to the device used, and to analyze the clinical and procedural variables of the lesions treated and identify the determinants of recurrence of restenosis and target lesion revascularization (TLR).

METHODS

Procedural and late outcomes for 58 lesions in 50 patients who underwent repeat intervention for in-stent restenosis were analyzed. The results of interventions according to the device employed were compared. The predictors of recurrence of restenosis and TLR within 6 months were analyzed. The ratio of balloon diameter in repeat intervention to minimal lumen diameter after initial stenting (MLD0) was used as an index of re-expansion of stents. Serial intravascular ultrasound imaging was performed before and after repeat intervention for 33 lesions, and re-expansion of the initial stent was evaluated.

RESULTS

Repeat intervention was successful in treating all lesions. Angiographic follow-up was possible for 49 lesions (84%). The overall incidences of recurrence of restenosis and TLR were 40.1 and 27.6%, respectively. Despite the immediate results having been good, the late results of stenting for in-stent restenosis were not favorable. Diffuse-type in-stent restenosis, early in-stent restenosis, and balloon diameter:MLD0 ratio > 1.25 are independent predictors of poor late results. Intravascular ultrasound findings have shown that expansion of the initial stent leads to recurrence of restenosis and TLR.

CONCLUSIONS

Re-expansion of the initial stent can cause further vascular injury and there is a risk of recurrence of restenosis. Alternative therapeutic strategies that work without dilating the initial stent may be necessary for treating lesions with high risk of recurrence of restenosis.

In-stent restenosis: long-term outcome and predictors of subsequent target lesion revascularization after repeat balloon angioplasty

OBJECTIVES

We sought to evaluate the long-term clinical outcome of patients undergoing successful balloon angioplasty for in-stent restenosis, and to determine correlates of the need for subsequent target lesion revascularization (TLR).

BACKGROUND

In-stent restenosis can be safely treated by repeat percutaneous intervention. Reported subsequent TLR rates have varied from 20% to 80% and seem related to the type of restenotic lesion.

METHODS

The study population comprised 234 patients with follow-up data who were successfully treated with repeat balloon angioplasty for in-stent restenosis in 257 lesions between May 1995 and January 1998 at our institution.

RESULTS

Clinical follow-up was available at 459 (286 to 693) days after the repeat procedure. Event-free survival was 78.5% and 74.6% at 12 and 24 months, respectively. Recurrent events occurred in 58 patients (24.8%), including 6 deaths (2.6%), 4 myocardial infarction (1.7%) and repeat target vessel revascularization in 50 patients (21.4%). Independent predictors of repeat TLR were time to in-stent restenosis <90 days (Hazard ratio 4.67, p < 0.001), minimal luminal diameter after repeat procedure (Hazard ratio 0.38, p = 0.034) and the angiographic pattern of in-stent restenosis (Hazard ratio 1.65, p = 0.036).

CONCLUSIONS

Balloon angioplasty is an effective means of treating in-stent restenosis. The long-term results are acceptable particularly for focal restenotic lesions. Further restenosis is more common in patients with early initial recurrence, more proliferative lesions and a poorer angiographic result from repeat angioplasty.

Effects of increasing balloon pressure on mechanism and results of balloon angioplasty for treatment of restenosis after Palmaz-Schatz stent implantation: an angiographic and intravascular ultrasound study

Repeat balloon angioplasty is a widely used therapeutic option for in-stent restenosis, but the optimal balloon inflation pressure has not yet been determined. We used angiography and intravascular ultrasound imaging to assess the mechanism and results of lumen enlargement at various inflation pressures. Thirteen consecutive patients with restenosis post-Palmaz-Schatz stent implantation were submitted to a four-step balloon angioplasty using increasing balloon pressure of 2, 4, 8, and >12 atm. As a global result, the lumen size was only 80% of that observed at stent implantation. Significant changes in angiographic minimal lumen diameter, minimal lumen cross-sectional area, and lumen volume were observed after each step except after the highest-pressure inflation. At low inflation pressure (<8 atm), the decrease in neointimal tissue and the stent over expansion explained the lumen enlargement, whereas after further high inflation pressure (>8 atm), only additional stent over expansion was observed. These results suggest that only moderate balloon inflation pressure (up to 12 atm) is needed for angioplasty of post-Palmaz-Schatz stent restenotic lesions.