In-Stent Restenosis: Pathophysiology and Treatment

Investigation of the Negative Emotions Exhibited in Patients with Coronary Heart Disease After PCI and Any Influencing Factors

Purpose

To understand existing negative emotions in patients with coronary heart disease after percutaneous coronary stent implantation (PCI) and analyse its influencing factors.

Methods

Patients with coronary heart disease after PCI in three tertiary hospitals in Changsha City from April to September 2018 were selected as the research subjects. The self-designed general information questionnaire assessed irritability, depression and anxiety (IDA) on a self-rating scale. It was used to examine patients’ existing negative emotions with coronary heart disease after PCI and analyse the influencing factors.

Results

203 questionnaires were distributed, and 202 valid questionnaires were recovered, with an effective recovery rate of 99.5%. The IDA score of patients with coronary heart disease after PCI was 17.01±7.60 points, the incidence of negative emotions was 63.8%, and the incidences of depression, anxiety and irritability were 39.6%, 8.4% and 15.8%, respectively. Negative emotion was taken as the dependent variable and a patient’s general data, such as lifestyle and disease, as the independent variables. A univariate analysis was conducted to obtain gender, age, educational level, marital status, work status, per capita monthly household income, sleep status, etc. Seven factors were identified as the influencing factors of negative emotions in patients with coronary heart disease after PCI, and the difference was statistically significant (P<0.05).

Conclusion

Most patients with coronary heart disease after PCI tend to exhibit negative emotions such as anxiety and depression. Medical staff should attach great importance to evaluating any negative feelings in this group and take timely targeted intervention measures to prevent and mitigate the occurrence and development of these adverse emotions in patients with coronary heart disease after PCI.

Predictors of Stent Restenosis in Han and Uygur Patients with Coronary Heart Disease after PCI in the Xinjiang Region

Background

Stent restenosis after PCI seriously affects the efficacy and prognosis; therefore, the study of ISR risk factors has become an urgent topic to be solved.

Objective

To investigate the risk factors for in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) in Han and Uygur patients with coronary heart disease.

Methods

The clinical data of 345 Han and 127 Uygur patients who underwent intracoronary stent implantation were divided into an ISR group and a non-ISR group. The general clinical data, laboratory indicators, and coronary artery lesions were compared.

Results

Age (OR = 1.040, 95% CI: 1.006∼1.075), triglycerides (OR = 1.440, 95% CI: 1.050∼1.973), total cholesterol (OR = 5.256, 95% CI: 2.826∼9.773), and ApoB (OR = 137.540, 95% CI: 11.364∼899.455) were independent risk factors for ISR after PCI in the Han patients, while ApoAI (OR = 0.002, 95% CI: 0.001∼0.011), MCV (OR = 0.824, 95% CI: 0.744∼0.911), MCH (OR = 0.421, 95% CI: 0.324∼0.548), and MCHC (OR = 0.934, 95% CI: 0.903∼0.965) were protective factors of ISR after PCI in Han patients, and the logistic regression equation composed of various factors predicted that the area under the ROC curve of ISR was 0.905. ApoB (OR = 11.571, 95% CI: 1.667∼80.340), Gensini score (OR = 1.017, 95% CI: 1.003∼1.031), and diabetes history (OR = 3.474, 95% CI: 1.189∼10.151) were independent risk factors for ISR after PCI in Uygur patients, and the area under ROC curve of ISR predicted by logistic regression equation is 0.807. The predictive efficiency of the Gensini score and ApoB level for ISR in Uygur patients was higher than that in Han, while the predictive efficiency of levels of ApoAI and MCH for ISR in Han patients was higher than that in Uygur (P < 0.05).

Conclusion

The independent risk factors for ISR after PCI in Han and Uygur patients in Xinjiang are different.

VDBP and VDR Mutations May Cause In-Stent Restenosis

Objective: In-stent restenosis (ISR) is the narrowing of a stented coronary artery lesion. A considerable number of patients undergoing percutaneous coronary intervention (PCI) are affected by ISR. The predominant mechanism in the development of ISR is an inflammatory response to vessel wall injury during PCI. Vitamin D is reported to have anti-inflammatory properties, so it may also be related with ISR. Therefore, in this study the relationship between vitamin D receptor (VDR), vitamin D binding protein (VDBP) gene variations and ISR were investigated. Methods: Fifty-eight ISR patients who have chest pain, underwent angiography and were found to have restenosis in the previously inserted stent were included in the patient group and thirty-five patients who have chest pain and were not found to have restenosis in their previous stent in coronary angiography were included in the control group. rs7041 and rs4588 variations in VDBP; rs1544410 and rs2228570 variations in VDR were investigated by real-time polymerase chain reaction (RT-PCR). Results were evaluated statistically. Results: The CC genotype of rs2228570 variation of VDR and the CA genotype of rs4588 variation of VDBP were found statistically high in patient group. rs7041 variation was found statistically high in patients who had myocardial infarction history before stent implantation. Additionally, it was demonstrated that vitamin D deficiency (vitamin D level

Diabetes and restenosis

Restenosis, defined as the re-narrowing of an arterial lumen after revascularization, represents an increasingly important issue in clinical practice. Indeed, as the number of stent placements has risen to an estimate that exceeds 3 million annually worldwide, revascularization procedures have become much more common. Several investigators have demonstrated that vessels in patients with diabetes mellitus have an increased risk restenosis. Here we present a systematic overview of the effects of diabetes on in-stent restenosis. Current classification and updated epidemiology of restenosis are discussed, alongside the main mechanisms underlying the pathophysiology of this event. Then, we summarize the clinical presentation of restenosis, emphasizing the importance of glycemic control in diabetic patients. Indeed, in diabetic patients who underwent revascularization procedures a proper glycemic control remains imperative.

Outcome of Wingspan Stent Using Aggressive Post-stent Balloon Dilation for Intracranial Atherosclerosis Stenosis

Background: Wingspan stent has gained interest for better long-term outcomes for intracranial atherosclerosis disease (ICAD). However, in-stent restenosis still presents as a problem and may cause postoperative neurological events. We aimed to find a way to prevent in-stent restenosis.

Method: Patients with stenosis >70% ICAD were treated with wingspan stent and were retrospectively reviewed. The patients were separated into two groups: one with post-dilation and the other without post-dilation. The outcomes of wingspan stenting were compared immediately after the surgery and at a 1-year follow-up.

Results: Overall, 28 patients were included for analysis, with 15 patients undergoing post-dilation and 13 patients not undergoing the procedure. The extent of stenosis was significantly lower in the post-dilation group than in the no post-dilation group, both immediately after the surgery (14.8 ± 10.2 vs. 28.5 ± 14.5%, p < 0.01) and at 1-year follow-up (25.8 ± 18.0 vs. 50.1 ± 23.2%, p < 0.01). The post-dilation method immediately expanded the stent diameter (2.89 ± 0.48 vs. 3.05 ± 0.44 mm, p < 0.001), and the diameter still increased at 1-year follow-up (3.05 ± 0.44 vs. 3.12 ± 0.43 mm, p < 0.01) due to the self-expandable property of the wingspan. Similarly, in the no post-dilation group, the stent size was also increased (2.70 ± 0.67 vs. 2.80 ± 0.64 mm, p < 0.01). However, at 1-year follow up, the luminal diameter was stationary in the post-dilation group (2.36 ± 0.73 vs. 2.46 ± 0.82 mm, p = 0.88) and decreased in the no post-dilation group (2.24 ± 0.56 vs. 1.60 ± 0.79 mm, p < 0.01). The periprocedural complication rate was similar between the groups.

Conclusion: The post-dilation method can be feasibly performed and can offer better stent expansion and apposition in the wingspan system. By applying this technique, we might prevent in-stent restenosis and improve neurological outcomes.

Increased risk of adverse cardiovascular events by strict glycemic control after percutaneous coronary intervention (HbA1c < 6.5% at 2 years) in type 2 diabetes mellitus combined with acute coronary syndrome: a 5-years follow-up study

OBJECTIVE

This study assessed the association between HbA1c level measured 2 years after percutaneous coronary intervention (PCI) and long-term clinical outcomes in type 2 diabetes mellitus combined with acute coronary syndrome (ACS) who underwent PCI.

METHODS

This prospective observational study analyzed 2877 ACS patients with type 2 diabetes mellitus whose baseline HbA1c ≥ 7.0% and underwent PCI. All patients were divided into 6 groups according to the HbA1c level at 2 years after PCI. The clinical outcome was major adverse cardiovascular events (MACEs), defined as all-cause death, all myocardial infarction, any revascularization, congestive heart failure, ischemic stroke. The median follow-up duration was 4.1 years.

RESULTS

All 2877 patients were divided into 6 groups: 2-year after PCI HbA1c < 6.0% (n = 219), 6.0-6.5% (n = 348), 6.5-7.0% (n = 882), 7.0-7.5% (n = 567), 7.5-8.0% (n = 441), ≥8.0% (n = 420). The 5-year incidence rate of MACEs in HbA1c <6.0% and 6.0-6.5% groups were similar to 7.5-8.0% and ≥8.0% groups, which were significantly higher than in 6.5-7.0% and 7.0-7.5% groups (p = .044). The cumulative incidence rate of MACEs significantly differed among the groups (p = .046). Multivariate Cox regression analysis revealed a U-shaped relationship between 2-year HbA1c level after PCI and risk of MACEs. 2-year HbA1c <6.5% after PCI was an independent risk factor for MACEs in type 2 diabetes mellitus combined with ACS who underwent PCI (p < .001).

CONCLUSIONS

The findings indicated an increased risk of MACEs by strict glycemic control after PCI (2-year HbA1c < 6.5% after PCI) in type 2 diabetes mellitus combined with ACS who underwent PCI.

High Sensitivity C-reactive Protein in Patients with Coronary Artery in-stent Restenosis: A Case-control Study

Background:

Inflammation plays a pivotal role in the pathogenesis of In-Stent Restenosis (ISR). High sensitivity C-reactive protein (hsCRP) is positively associated with major cardiovascular events.

Aim:

We aimed to investigate the hsCRP inflammatory response to Percutaneous Coronary Intervention (PCI) in Coronary Artery Disease (CAD) patients with coronary ISR vs. patients without ISR.

Methods:

This case-control study included 80 CAD patients previously treated with drug-eluting stent (DES) implantation. Patients had Coronary Angiography (CAG) because of chest pain or equivalent symptoms and were subdivided into 2 groups. Group A (n=40) included CAD patients with ISR. Group B (n=40) included age and gender-matched controls with CAD but without ISR. Serum hsCRP levels were obtained before PCI (baseline) and 8, 16, 24 h post-PCI.

Results:

At baseline (before intervention/CAG), the hsCRP level was increased in the ISR group compared with the No-ISR group (p=0.007). There were 36 (90%) patients in the ISR group who had a high hsCRP (>3 mg/L) compared with 25 (62.5%) patients in the No-ISR group. Also, there was a significant relationship between high hsCRP and the ISR. Patients with ISR had higher frequencies and percentages of elevated CRP than the no-ISR control group. This difference was maintained for all measurements, baseline, after 8, 16, and 24 h (p<0.05). Repeated measures analysis of variance (ANOVA) in the ISR group revealed that mean hsCRP differed significantly between serial measurements (p<0.001). In contrast, in the control group, the mean hsCRP did not differ significantly between the serial measurements (p=0.65).

Most of our patients (n=66, 82.5%) had 1-vessel CAD disease, and the left anterior descending (LAD) coronary artery was significantly affected in 46 patients (57.5%). Management of restenosis was accomplished mainly by stenting by DES in 29 patients (72.5%).

Conclusion:

Patients with ISR had substantially higher pre- and post-PCI hsCRP levels than the no-ISR controls. This difference was maintained up to 24h post-PCI. Conversely, the mean hsCRP did not significantly differ at the follow-up points for the controls without ISR.

Circulating level of microRNA-142-5p is a potential biomarker for predicting in-stent restenosis: a case-control study

Background

Patients who receive percutaneous coronary intervention (PCI) have different chances of developing in-stent restenosis (ISR). To date, no predictable biomarker can be applied in the clinic. MicroRNAs (miRNAs or miRs) play critical roles in transcription regulation, and their circulating levels were reported to have potential as clinical biomarkers.

Methods

In total, 93 coronary stent-implanted patients without pregnancy, liver or renal dysfunction, malignancy, hemophilia, or autoimmune diseases were recruited in this clinical study. All recruited participants were divided into an ISR group (n = 45) and a non-ISR group (n = 48) based on their restenotic status as confirmed by cardiologists at the first follow-up visit (6 months after surgery). Blood samples of all participants were harvested to measure circulating levels of miRNA candidates (miR-132, miR-142-5p, miR-15b, miR-24-2, and miR-424) to evaluate whether these circulating miRNAs can be applied as predictive biomarkers of ISR.

Results

Our data indicated that circulating levels of miR-142-5p were significantly higher in the ISR population, and results from the receiver operating characteristic (ROC) curve analysis also demonstrated superior discriminatory ability of miR-142-5p in predicting patients’ restenotic status. In addition, circulating levels of miR-15b, miR-24-2, and miR-424 had differential expressions in participants with diabetes, hyperlipidemia, and hypertension, respectively.

Conclusions

The current study revealed that the circulating level of miR-142-5p has potential application as a clinical biomarker for predicting the development of ISR in stent-implanted patients.

A Systematic Review on Bleeding Risk Scores' Accuracy after Percutaneous Coronary Interventions in Acute and Elective Settings

Dual antiplatelet therapy (DAT) is recommended for all patients undergoing percutaneous coronary intervention (PCI), as it significantly reduces the ischemic risk at the cost of increasing the incidence of bleeding events. Several clinical predictive models were developed to better stratify the bleeding risk associated with DAT. This systematic review aims to perform a literature survey of both standard and emerging bleeding risk scores and report their performance on predicting hemorrhagic events, especially in the era of second-generation drug-eluting stents and more potent P2Y12 inhibitors. We searched PubMed, ScienceDirect, and Cochrane databases for full-text studies that developed or validated bleeding risk scores in adult patients undergoing PCI with subsequent DAT. The risk of bias for each study was assessed using the prediction model risk of bias assessment tool (PROBAST). Eighteen studies were included in the present systematic review. Bleeding risk scores showed a modest to good discriminatory power with c-statistic ranging from 0.49 (95% CI, 0.45-0.53) to 0.82 (95% CI, 0.80-0.85). Clinical models that predict in-hospital bleeding events had a relatively good predictive performance, with c-statistic ranging from 0.70 (95% CI, 0.67-0.72) to 0.80 (95% CI, 0.73-0.87), depending on the risk scores and major hemorrhagic event definition used. The knowledge and utilization of the current bleeding risk scores in appropriate clinical contexts could improve the prediction of bleeding events.

Preventing treatment failures in coronary artery disease: what can we learn from the biology of in-stent restenosis, vein graft failure, and internal thoracic arteries?

Coronary artery disease (CAD) remains one of the most important causes of morbidity and mortality worldwide, and the availability of percutaneous or surgical revascularization procedures significantly improves survival. However, both strategies are daunted by complications which limit long-term effectiveness. In-stent restenosis (ISR) is a major drawback for intracoronary stenting, while graft failure is the limiting factor for coronary artery bypass graft surgery (CABG), especially using veins. Conversely, internal thoracic artery (ITA) is known to maintain long-term patency in CABG. Understanding the biology and pathophysiology of ISR and vein graft failure (VGF) and mechanisms behind ITA resistance to failure is crucial to combat these complications in CAD treatment. This review intends to provide an overview of the biological mechanisms underlying stent and VGF and of the potential therapeutic strategy to prevent these complications. Interestingly, despite being different modalities of revascularization, mechanisms of failure of stent and saphenous vein grafts are very similar from the biological standpoint.

Usefulness of Intracoronary Brachytherapy for Patients With Resistant Drug-Eluting Stent Restenosis

In-stent restenosis (ISR) remains a concern even in the drug-eluting stent (DES) era and carries a high risk of recurrence. Brachytherapy is being used as an alternative treatment for resistant ISR, yet the safety and efficacy of this approach has not been well studied. We analyzed the outcomes of 101 patients who underwent coronary brachytherapy for resistant DES ISR. Baseline demographic, clinical, procedural, and outcome data were collected by phone and from electronic records. Comorbidities and overt cardiovascular disease were highly prevalent. Median previous stent layers were 2 with a maximum of 5 layers. Procedural angiographic success rate was 97% and median time to discharge was 1 day after brachytherapy. The primary outcome of target vessel revascularization was 24% at 1 year, 32% at 2 years, and 42% at 3 years. The rate of nonfatal myocardial infarction was 0% at 1 year, 3.5% at 2 years, and 6% at 3 years. The rate of all-cause mortality was 8.5% at 1 year, 12% at 2 years, and 16% at 3 years. We observed only 1 case of late stent thrombosis. After multivariable adjustment, female gender (hazard ratio 2.37, 95% confidence interval 1.02 to 5.52, p = 0.04) and diffuse ISR pattern (hazard ratio 2.95, 95% confidence interval 1.21 to 7.17, p = 0.01) were independently associated with the primary outcome. In conclusion, brachytherapy is feasible for the treatment of resistant DES ISR and is associated with high immediate procedural success and reasonable efficacy in a complex patient population. This approach might be used as an alternative for these patients.

Comparison of drug-eluting balloon versus drug-eluting stent treatment of drug-eluting stent in-stent restenosis: A meta-analysis of available evidence

BACKGROUND

In-stent restenosis (ISR) remains an important concern despite the recent advances in the drug-eluting stent (DES) technology. The introduction of drug-eluting balloons (DEB) offers a good solution to such problem.

OBJECTIVES

We performed a meta-analysis to assess the clinical efficiency and safety of DEB compared with DES in patients with DES-ISR.

METHODS

A systematic search was conducted and all randomized and observational studies which compared DEB with DES in patients with DES-ISR were included. The primary outcome measure-major adverse cardiovascular events (MACE)-as well as individual events as target lesion revascularization (TLR), stent thrombosis (ST), myocardial infarction (MI), cardiac death (CD) and all-cause mortality, were analyzed.

RESULTS

Three randomized and 4 observational studies were included with a total of 2052 patients. MACE (relative risk [RR]=1.00, 95% confidence interval (CI) 0.68 to 1.46, P=0.99), TLR (RR=1.15 [CI 0.79 to 1.68], P=0.44), ST (RR=0.37[0.10 to 1.34], P=0.13), MI (RR=0.97 [0.49 to 1.91], P=0.93) and CD (RR=0.73 [0.22 to 2.45], P=0.61) were not different between patients treated with DEB and with DES. However, all-cause mortality was lower in patients treated with DEB (RR=0.45 [0.23 to 0.87, P=0.019) and in particular when compared to only first generation DES (RR 0.33 [0.15-0.74], P=0.007). There was no statistical evidence for publication bias.

CONCLUSIONS

The results of this meta-analysis showed that DEB and DES have similar efficacy and safety for the treatment of DES-ISR.

Peripheral Atherectomy: Applications and Techniques

Peripheral atherectomy is a class of procedures that is rapidly increasing in volume. Multiple classes of devices exist, and newer variants are added to the market annually. The devices see wide application for de novo lesions, in-stent restenosis, and adjunctive therapy for drug-coated balloons. The body of evidence supporting atherectomy is less robust than for many other peripheral therapies. The frequency and severity of complications from atherectomy can be significant compared with angioplasty and stenting, and familiarity with preventative and bailout techniques is essential for the interventionalist.