Treatment Strategies for In‐Stent Restenosis

Abstract

In‐stent restenosis has become a significant clinical problem. It is estimated that in 1997, up to 100,000 patients with in‐stent restenosis were treated worldwide. Serial intravascular ultrasound analysis has shown that neointimal hyperplasia represents the most important cause for in‐stent restenosis, while late recoil and remodeling are neglectabe. With the recent explosion in the use of coronary stents, clinical investigation on stent restenosis has lagged behind. For example, the true prevalence of in‐stent restenosis varies with the lesion and patient subset. It is much higher in the “real world” than in selected patients who are typically controlled in most studies. Diffuse restenosis can be expected in about two‐thirds of stented patients, and it is difficult to treat because of unfavorable long‐term results. Conventional catheter‐based treatment modalities include plain balloon angioplasty (PTCA), rotational atherectomy (RA), excimer laser coronary angioplasty (ELCA), directional coronary atherectomy (DCA), and additional stent implantation. Exact individual recurrence rates for these approaches are not known and show a considerable degree of variability. Recently, brachytherapy has emerged as the most promising way to treat in‐stent restenosis.