Balloon Angioplasty For In-stent Restenosis Research Articles

In-stent tissue characteristics detected by optical coherence tomography may affect re-restenosis after cutting balloon angioplasty for in-stent restenosis

Purpose: Cutting balloon angioplasty (CBA) is one of proposed treatments for in-stent restenosis (ISR) but re-restenosis rate after CBA is relatively high. In this study, we investigated whether optical coherence tomography (OCT) detected tissue characteristics can affect re-restenosis after CBA for ISR. Methods: Seventy consecutive patients with ISR who received OCT-guided CBA were enrolled. We divided our patients into TLR group in whom we performed target lesion revascuralization (TLR) for re-restenosis over 3 months after CBA for ISR and non-TLR group in whom we didn't perform TLR. We compared the incidence of drug-eluting stent, phase of ISR, ISR pattern, balloon size, maximal inflation pressure and the OCT parameters of ISR before CBA including restenotic tissue structure/backscatter, microvessels, thrombus and minimum lumen area between the two groups. Results: The rate of TLR was 21.4%. The incidence of microvessels, thrombus and heterogeneous or layered pattern in TLR group (n=15) was significantly higher than non-TLR group (n=55) while the other parameters showed non-significant differences (table). View this table: Table 1 Conclusions: The incidence of microvessels, thrombus and heterogeneous or layered pattern in ISR tissue detected by OCT may affect re-restenosis after CBA for ISR.

Drug-eluting balloon angioplasty for in-stent restenosis: a systematic review and meta-analysis of randomised controlled trials

ContextThe optimal treatment option for in-stent restenosis is currently unclear.ObjectiveSystematic review and meta-analysis of the effect of drug-eluting balloons (DEB) to treat in-stent restenosis.Data sourcesTrials were identified through a literature...

Kissing drug eluting balloons for in-stent restenosis complicating bifurcations treated with drug-eluting stents

The management of in-stent restenosis (ISR) complicating bifurcation lesions is technically challenging and implant of further stents may not be feasible. The use of drug-eluting balloons provides an attractive option for treatment of such lesions allowing a technically simple procedure without the need for further complex stenting. The SeQuent Please paclitaxel-eluting balloon (B. Braun, Berlin, Germany) has been shown to be superior to a paclitaxel eluting stent or balloon angioplasty for ISR complicating a bare-metal stent. However, there is no data on the efficacy of the SeQuent Please in ISR complicating drug-eluting stents or bifurcation lesions. We report two cases where the SeQuent Please was used in this setting with angiographic success and freedom from target vessel failure and angina at 24 months. In both cases the Sheathless Eau Cath guide (Asahi Intecc, Japan) was employed to perform a kissing-balloon dilatation with the SeQuent Please, so allowing treatment via radial access.

Analysis of Potential Cost-Savings After Introduction of Drug-Eluting Balloon Angioplasty for In-Stent Restenosis or Small Vessel Disease

Background and ObjectivesThe drug-eluting balloon (DEB) catheter system was developed to treat restenosis. Furthermore, DEB angioplasty has been shown to reduce restenosis risk when compared to drug-eluting stents (DES) in patients with in-stent restenosis (ISR) or small vessel disease (SVD). In addition, DEB angioplasty reduces costs due to fewer revascularizations and reduced clopidogrel treatment length. The objective of this study was to predict the expected cost-savings when DEB is substituted for DES in patients with ISR or SVD.Subjects and MethodsThe subjects included were patients treated by DES at Seoul National University Hospital from January 2006 to June 2009, with clinical data after percutaneous coronary intervention, were. A model was developed to allow the costs of DES and the calculated costs of DEB incurred by patients with ISR or SVD to be compared. The overall cost of DEB was calculated to be 1,256,150 won and the overall cost of DES was 2,102,500 won, and the cost of clopidogrel was 2,168 won. Expected repeat revascularizations within 12 months of DEB were calculated based on information provided by the Paclitaxel-Eluting PTCA-Balloon Catheter in Coronary Artery (PEPCAD) I and II trials.ResultsBy substituting DEB for DES, total cost (including the cost of initial DEB treatment, the cost of repeat revascularization after DEB treatment, and the cost of clopidogrel treatment) was found to be 34% lower in ISR patients and 48% lower in SVD patients.ConclusionDEB angioplasty will significantly reduce costs as compared to DES in ISR and in SVD patients.

Optical coherence tomography after new scoring balloon angioplasty for in-stent restenosis and de novo coronary lesions

The AngioSculpt™ scoring balloon catheter (AngioScore, Inc., Fremont, California) has recently been developed for percutaneous intervention in coronary and peripheral arteries. This device is composed of two major components, a minimally compliant balloon and three nitinol wore. The three wires encapsulate the low-compliant balloon in a spiral configuration. The concept is for the spiral wires to score the lumen surface during balloon expansion. However, the precise mechanisms and efficacy of this scoring technology in humans had not yet to be determined. In this case, both a de novo coronary lesion and an in-stent restenosis lesion were treated with the scoring balloon and were subsequently observed via optical coherence tomography (OCT) with high-resolution images (≈ 15 μm). OCT clearly demonstrated the effects of this device on plaque and neointimal hyperplasia scoring, as well as its ability to achieve sufficient lumen sizes after coronary artery dilatation.

Catheter Entrapment During Balloon Angioplasty in Patient With In-Stent Restenosis: An Unusual Complication and Its Surgical Management

Entrapment of coronary angioplasty hardware is one of the rare complications of percutaneous coronary artery interventions. We reported herein a case of 58-year-old man with an entrapped balloon catheter and guidewire within the right coronary artery during the application of a conventional balloon angioplasty for in-stent restenosis. Surgical removal of the entrapped balloon catheter and guidewire was performed successfully with a coronary artery bypass grafting to the affected vessel. The application of the balloon angioplasty for in-stent restenosis requires every caution against such type of complications.

Percutaneous safenectomy: A potentially dreadful complication of cutting balloon angioplasty in safenous vein grafts

Vessel perforation is an uncommon but potentially life-threatening complication of percutaneous coronary intervention and is often associated with the use of atheroablative devices. While effective management means are currently available, such as PTFE-covered stent, pericardiocentesis, and perfusion balloon, a timely and skillful approach is of paramount importance to solve this dreadful complication. We hereby describe a case of saphenous vein graft (SVG) perforation occurring after cutting balloon angioplasty for in-stent restenosis. Despite the immediate occurrence of cardiac arrest due to massive extravasation of contrast in the mediastinum with pericardial tamponade, deep catheter intubation enabled the deployment of two PTFE-covered stents and subsequent sealing of the leak with repeated inflation of a perfusion balloon, while hemopericardium was drained by pericardiocentesis. This clinical vignette emphasizes the role of optimal backup in order to deploy life-saving devices and successfully manage life-threatening pericardial tamponade due to SVG rupture.

Cutting Balloon Angioplasty versus Conventional Balloon Angioplasty for In-Stent Restenosis Treated by Intracoronary Radiation Therapy

Background: Cutting Balloon angioplasty (CBA) may be a useful treatment modality for in-stent restenosis (ISR) as it maintains a stable position during dilatation and results in potentially less injury than plain old balloon angioplasty (POBA). The purpose of this study was to compare CBA and POBA with intracoronary radiation therapy (IRT) for in-stent restenosis (ISR). Methods: We selected 157 consecutive patients from the WRIST (Wa- shington Radiation for In-stent restenosis Trial) series of gamma radiation trials using both gamma and beta emitters for ISR of native coronaries or saphenous vein grafts, who were treated with CBA or POBA as the only treatment strategy before intracoronary radiation therapy. Patients in the CBA (N=64) and POBA (N=93) groups were matched for baseline demographic and procedural characteristics. Radiation was delivered successfully in all cases. Results: At angiographic follow up, acute gain was higher in the CBA group than the POBA group (1.7±0.7 mm vs. 1.4±0.9 mm, p=0.03). The angiographic restenosis rate (17.1% vs. 23.5%, p=NS) and edge restenosis rate (6.3% vs. 12.2%, p=NS) were not significantly lower in the cutting balloon cohort. At a 6 month clinical follow up, the CBA group showed a statistically decreased rate of clinically driven target vessel revascu- larization compared to the POBA group (5.7% vs.18.3%, p=0.038). Conclusions: Cutting balloon angioplasty is a reasonable treatment strategy for in-stent restenosis prior to intracoronary radiation therapy. (Korean Circulation J

Inadvertent intracoronary stent extraction 10 months after implantation complicating cutting balloon angioplasty for in-stent restenosis

We report the case of an unusual complication for Cutting Balloon Angioplasty (CBA) during treatment for instent restenosis (ISR), which resulted in inadvertent intracoronary stent extraction 10 months after implantation. In this case report, CBA was utilized to treat an ISR lesion in the distal right coronary artery (RCA). Due to difficulty in withdrawing the cutting balloon into the guide after treatment of the lesion, the entire system (guide, cutting balloon, and guidewire) was removed as a unit from the body. Upon examination of the system, the previously placed stent in the distal RCA was attached to the microtomes of the cutting balloon. Although the precise mechanisms for stent extraction in this case remain speculative, the initial stent used in the distal RCA may have been undersized, and this may have played a major role in this complication. Although there is limited data regarding the optimal strategy to treat the site of the inadvertent stent extraction, we opted to re-stent the area with a properly-sized coronary stent. Following the intervention, there was no residual stenosis with TIMI 3 flow through the vessel. The patient remained asymptomatic and a serum troponin drawn 18 hours after the procedure was normal, and he was discharged the next day. The interventionist must be vigilant about this rare but serious complication when applying CBA in the treatment of ISR, particularly when an undersized or underdeployed stent is suspected.

Mechanism of cutting balloon angioplasty for in-stent restenosis: an intravascular ultrasound study.

We investigated by intravascular ultrasound (IVUS) the mechanism of action of cutting balloon (CB) angioplasty in patients with in-stent restenosis. Seventy-one consecutive restenotic lesions of 66 patients were studied by quantitative coronary angiography (QCA) and IVUS before, immediately after, and, in 20 cases, at 24-hr time interval after CB. CB was selected according to 1:1 CB-to-stent ratio and inflated at 8 atm for 60-90 sec. Both IVUS planar and volumetric (Simpson's rule, 25 patients) analysis were carried out. IVUS measurements included external elastic membrane area (EEMA), stent area (SA), minimal lumen area (MLA), and restenosis area (RA). Following CB, QCA analysis showed increase of minimal lumen diameter (1.17 +/- 0.46 vs. 2.45 +/- 0.51 mm; P < 0.0001) and decrease of diameter stenosis (64% +/- 13% vs. 21% +/- 9%; P < 0.0001). IVUS measurements showed a significant increase of MLA (2.18 +/- 0.80 vs. 7.31 +/- 1.8 mm(2); P < 0.0001), SA (9.62 +/- 2.6 vs. 10.7 +/- 2.75 mm(2); P < 0.0001), and EEMA (17.27 +/- 5 vs. 18.1 +/- 5 mm(2); P < 0.0001) and a decrease of RA (7.43 +/- 2.63 vs. 3.45 +/- 1.39 mm(2); P < 0.0001). No significant change was observed in the original plaque + media area (7.65 +/- 3 vs. 7.38 +/- 2.9 mm(2); P = NS). Thus, of the total lumen enlargement (5.13 +/- 1.85 mm(2)), 23% was the result of increase in mean SA, whereas 77% was the result of a decrease in mean RA. These changes were associated with a 5% increase in EEMA. IVUS volumetric changes paralleled planar variations. Angiographic and IVUS changes were well maintained at 24 hr. CB enlarges coronary lumen mainly by in-stent tissue reduction associated with a moderate degree of additional stent expansion. Favorable QCA and IVUS acute results are maintained at 24 hr.

Different mechanism of lumen enlargement in lesions with stent underexpansion after balloon angioplasty for in-stent restenosis compared to those with optimal stent expansion: an intravascular ultrasound study

Different mechanism of lumen enlargement in lesions with stent underexpansion after balloon angioplasty for in-stent restenosis compared to those with optimal stent expansion: an intravascular ultrasound study

Long-term angiographic follow-up after successful repeat balloon angioplasty for in-stent restenosis.

Coronary stent implantation is associated with improved angiographic short-term and mid-term clinical outcome. However, restenosis rate still remains between 20 and 30%. The purpose of the study, performed as a prospective angiographic follow-up to detect restenosis, was to evaluate the immediate and the 6-month angiographic results of repeat balloon angioplasty for in-stent restenosis. From April 1996 to September 1997, 335 stenting procedures performed in 327 patients underwent prospectively 6-month control angiography. Of the 96 lesions that showed in-stent restenosis (> 50% diameter stenosis) (29%), 72 underwent balloon angioplasty. The primary success rate was 100%. Follow-up angiogram at a mean of 6.9 +/- 2.4 months was obtained in 54 patients. Recurrent restenosis was observed in 24 of the 55 stents (44%). Repeat intervention for diffuse and body location in-stent restenosis before repeat intervention was associated with significantly higher rates of recurrent restenosis (p < 0.001 and p < 0.05, respectively). Of the 19 patients who underwent further balloon angioplasty (100% success rate), coronary angiography was performed in 18 (95%) at a mean of 8.2 +/- 2.0 months and showed recurrent restenosis in 12 patients (67%). Further repeat intervention for diffuse and severe in-stent restenosis before the second repeat intervention was associated with significantly higher rates of further recurrent restenosis (p < 0.05 and p < 0.005, respectively). Although balloon angioplasty can be safely, successfully, and repeatedly performed after stent restenosis, it carries a progressively high recurrence of angiographic restenosis rate during repeat 6-month follow-ups. The subgroup of patients with diffuse, severe, and/or body location in-stent restenosis proved to be at higher risk of recurrent restenosis.

Mechanism of lumen enlargement during cutting balloon angioplasty for in-stent restenosis: An intravascular ultrasound study Javed M. Ahmed, Gary S. Mintz, Marco Castagna, Neil J. Weissman, Lowell F. Satler, Kenneth M. Kent, Augusto D. Pichard. Washington Hospital Center, Washington, DC

Mechanism of lumen enlargement during cutting balloon angioplasty for in-stent restenosis: An intravascular ultrasound study Javed M. Ahmed, Gary S. Mintz, Marco Castagna, Neil J. Weissman, Lowell F. Satler, Kenneth M. Kent, Augusto D. Pichard. Washington Hospital Center, Washington, DC

Early lumen loss after repeat coronary intervention for in‐stent restenosis

The purpose of this study was to compare the effects of balloon angioplasty versus repeat stenting on the early angiographic outcome in patients with in-stent restenosis. The treatment of in-stent restenosis using balloon angioplasty alone often yields excellent early results, but is associated with a high rate of late recurrence. In the SCRIPPS trial, patients with restenosis were treated either with balloon angioplasty alone or placement of additional stents to optimize angiographic results before randomization and exposure of the restenotic segment to gamma radiation or placebo. In patients undergoing repeat catheter based intervention for the treatment of in-stent restenosis, quantitative coronary angiography was used to compare the results of balloon angioplasty alone versus repeat stenting on early lumen loss. After a mean delay time interval of 71 min, the early loss was 0.35 ± 0.34 mm in the balloon angioplasty alone group compared to 0.01 ± 0.34 mm in the repeat-stenting group (P = 0.004). The early loss index in the balloon angioplasty alone group (12.8 ± 12.9%) was significantly greater than in the repeat stenting group (0.7 ± 12.1%; P = 0.003). Although balloon angioplasty for in-stent restenosis often provides excellent immediate angiographic results, luminal diameters are significantly reduced in the early time period after balloon dilatation. Repeat stenting nearly abolishes this early luminal loss. Cathet Cardiovasc Intervent 2001;52:35–38. © 2001 Wiley-Liss, Inc.

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

OBJECTIVESWe 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).BACKGROUNDIn-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.METHODSThe 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.RESULTSClinical 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).CONCLUSIONSBalloon 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.

Cutting balloon angioplasty for in-stent restenosis.

Catheterization and Cardiovascular InterventionsVolume 50, Issue 4 p. 480-483 Catheterization Curriculum Cutting balloon angioplasty for in-stent restenosis Arvinder S. Kurbaan MD, Corresponding Author Arvinder S. Kurbaan MD a_kurbaan@hotmail.com Department of Cardiology, London Chest Hospital, London, United KingdomDepartment of Cardiology, London Chest Hospital, Bonner Road, London E2 9SX, United KingdomSearch for more papers by this authorRodney A. Foale MD, Rodney A. Foale MD Department of Cardiology, St Mary's Hospital, London, United KingdomSearch for more papers by this authorUlrich Sigwart MD, Ulrich Sigwart MD Department of Cardiology, Royal Brompton Hospital, London, United KingdomSearch for more papers by this author Arvinder S. Kurbaan MD, Corresponding Author Arvinder S. Kurbaan MD a_kurbaan@hotmail.com Department of Cardiology, London Chest Hospital, London, United KingdomDepartment of Cardiology, London Chest Hospital, Bonner Road, London E2 9SX, United KingdomSearch for more papers by this authorRodney A. Foale MD, Rodney A. Foale MD Department of Cardiology, St Mary's Hospital, London, United KingdomSearch for more papers by this authorUlrich Sigwart MD, Ulrich Sigwart MD Department of Cardiology, Royal Brompton Hospital, London, United KingdomSearch for more papers by this author First published: 27 July 2000 https://doi.org/10.1002/1522-726X(200008)50:4<480::AID-CCD24>3.0.CO;2-2Citations: 23AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume50, Issue4August 2000Pages 480-483 SCAI Member Sign in RelatedInformation

Local heparin delivery for prevention of second in-stent restenosis. Acute and long-term results in 47 consecutive cases.

BACKGROUND: Heparin has been shown to reduce intimal thickening after arterial wall injury by inhibiting vascular smooth muscle cell proliferation and migration. The authors studied the acute and long-term results after local delivery of heparin after balloon angioplasty for in-stent restenosis. METHODS AND RESULTS: Forty-seven in-stent restenosis cases, 32 of them longer than 1 cm, were enrolled. After angioplasty local heparin delivery was performed using the Dispatch coronary infusion catheter (Scimed Life Systems/Boston Scientific Corp, Natick, MA, USA); the infusion rate was 99.9 ml per hour and a target dosage of 4000 iu heparin per site was intended to be delivered. In nine cases (19.15%) heparin delivery had to be stopped because of ischemia. One patient died six days after intervention. After a follow-up interval of 6-12 months target vessel revascularization rate was 28.26%. CONCLUSIONS: For the protocol used ischemia occurred more often than previously reported. Considering the fact that most patients had diffuse in-stent restenosis, the target revascularization rate at follow-up was acceptable.

Intravascular ultrasound-guided balloon angioplasty for treatment of in-stent restenosis

We investigated the usefulness of intravascular ultrasound (IVUS)-guided balloon angioplasty for in-stent restenosis in 37 lesions of 34 consecutive patients. We divided these patients into two groups: a group in which the balloon size was determined by quantitative coronary angiography (QCA group; 17 patients, 19 lesions) and a group in which the balloon size was determined by IVUS (IVUS group; 17 patients, 18 lesions). We compared short-term and 6-month outcomes for these groups. In the IVUS group, we used a balloon of a size equal to 95% of the media-to-media diameter at the distal to the stent, as determined by IVUS. No significant differences were observed in patient or lesion characteristics between the two groups. The clinical success rate was 100% in both groups, and no clinical events were observed in either of the groups. The balloon/artery ratio was larger in the IVUS group than in the QCA group (1.33 +/- 0.35 vs. 1.16 +/- 0.13, P < 0.05), and the recurrent restenosis rate was lower (17% vs. 53%, P < 0.05). These results suggest that repeat balloon angioplasty using a balloon size determined by IVUS is useful for in-stent restenosis. Cathet. Cardiovasc. Intervent. 47:298-303, 1999.

Long-term outcome and determinants of event-free survival in patients treated with balloon angioplasty for in-stent restenosis

Long-term prognosis and predictors of event-free survival were studied in 56 consecutive patients with in-stent restenosis successfully treated with balloon angioplasty. Most patients sustained prolonged clinical benefit, but during follow-up, those with diabetes or with a short time interval (<4 months) from stenting to repeat angioplasty experienced adverse cardiac events more often.

Clinical Follow-up of Excimer Laser Coronary Angioplasty for In-stent Restenosis

Background and Objectives:Previous studies have shown a high restenosis rate after balloon angioplasty for diffuse in-stent restenosis. Debulking strategy has been expected to be helpful to reduce the restenosis rate. This study evaluated the safety and long-term clinical event rate after excimer laser coronary angioplasty (ELCA) and adjunctive balloon angioplasty for in-stent restenosis. Materials and Method:We included 29 in-stent restenotic lesions treated in 28 patients (18 men, 10 women, mean age 60±2 years) admitted to Samsung Medical Center between June 1997 and August 1998. Quantitative coronary angiography was performed and clinical characteristics, acute complications, 30-day and 8-month major cardiac adverse event rate was analyzed. Results: Initial success rate was 97%. We stopped the ELCA procedure in one lesion located in the proximal left anterior descending artery due to bradycardia and hypotension. In the 28 lesions successfully treated with ELCA and adjunctive balloon angioplasty, the minimal luminal diameter increased from 0.7±0.1 mm before ELCA to 1.9± 0.1 mm after ELCA and to 2.7±0.1 mm after adjunctive balloon angioplasty (p<.0001). The acute luminal gain after ELCA was 60%. The diameter stenosis decreased from 75±2% before ELCA to 36±2% after ELCA and to 15±2% after adjunctive balloon angioplasty (p<.0001). There was no in-hospital death, Q wave acute myocardial infarction (AMI), emergency coronary artery bypass graft (CABG), but non-Q AMI was noted in 1 case (3%). During the followed-up period of 8 months, there were 1 death (4%) due to congestive heart failure, 1 nonQ-AMI (4%) and 7 target lesion revascularization (26%) among the successfully treated 27 patients, but there was no CABG, Q-AMI. Combined event rate at the 8-month follow-up was 33% and target lesion revascularization rate at 8-month follow-up was 26%. Conclusion:The ELCA and adjunctive balloon angioplasty seems to be safe and effective for the treatment of in-stent restenosis. A prospective randomized trial comparing ELCA versus other ablative technique is required. (Korean Circulation J 1999;29(9):891-897)