Abstract
Treatment of in-stent restenosis (ISR) with conventional PTCA causes significant recurrent neointimal tissue growth in 30-85% of the cases. Therefore, laser ablation of intra-stent neointimal hyperplasia prior to balloon dilatation can be an attractive alternative. However, the long-term outcomes of such treatment have not been studied thoroughly enough. This prospective case-control study evaluated angiographic and clinical outcomes of PTCA alone and a combination of excimer laser coronary angioplasty (ELCA) and adjunct PTCA in 125 patients with ISR. ELCA was performed prior to balloon dilatation in 67 patients, PTCA alone was performed in 58 patients. Basic demographic and clinical data were comparable in both groups. Lesions included in ELCA group were longer (17.1±9.9 mm versus 13.6±9.1 mm; p=0.034), more complex (36.5% type-C stenoses versus 14.3%; p=0.006) and more frequently had reduced distal blood flow (TIMI < 3: 18.9% versus 4.8%; p=0.025) compared to lesions in PTCA group. Immediate angiographic results of PTCA and ELCA+PTCA appeared to be comparable. PTCA alone was successful in 57 patients (98.3%), ELCA+PTCA - in 66 patients (98.5%). The rates of hospital complications were comparable (3.0% in ELCA group versus 8.6% in PTCA group). The 1 year-follow-up showed that the rates of MACE were comparable in the two groups (37.3% in ELCA group versus 46.6% in PTCA group). The rates of TVR within 1 year after the intervention were also similar in ELCA and PTCA groups (32.8% versus 34.5%). The data mean that ELCA in patients with complex ISR is efficient and safe. Despite a higher complexity of lesions in ELCA group, no increase in the rate of complications was registered.
Highlights
The randomized clinical research has demonstrated a greater efficacy of coronary stenting (CS) in comparison with percutaneous transluminal coronary angioplasty (PTCA) for the treatment of native coronary lesions in patients with coronary artery disease (CAD) (1,2)
excimer laser coronary angioplasty (ELCA) was performed in 67 patients (ELCA group); it was immediately followed by PTCA
There is an acute demand for the best strategy to treat in-stent restenosis, because the number of stent implantations and ISR after the intervention are increasing every year, and the recurrence rate for dilated restenotic vessels is varying from 30% to 85% (17-19)
Summary
The randomized clinical research has demonstrated a greater efficacy of coronary stenting (CS) in comparison with percutaneous transluminal coronary angioplasty (PTCA) for the treatment of native coronary lesions in patients with coronary artery disease (CAD) (1,2). Stents have been widely used for efficient treatment of coronary lesions of various complexity. In USA alone the number of patients with in-stent restenosis (ISR) is over 150000 a year (6). It is known that restenosis after PTCA is determined by early elastic recoil, subsequent contraction of the dilated vessel, thrombosis at the site of dilatation, major proliferation with migration to intimal tissue and overproduction of extracellular matrix (7-9). Intravascular ultrasound (IVUS) studies have shown that elastic recoil and subsequent contraction of the dilated vessel are virtually absent after CS (9,11,12). In-stent restenosis results totally from neointimal hyperplasia within the axial stent length and at the margins of the stented segment (12-14)
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