In-stent Restenosis Lesions Research Articles

Five factors and three characteristics of coronary in-stent restenosis.

In the field of interventional cardiology, several patient subsets still present with poor clinical and angiographic outcomes after drug-eluting stent (DES) implantation. The author of this editorial comment supports the idea that in-stent restenosis (ISR) includes three characteristics (severity and extent of stenosis, and tissue characteristics) that are caused by five factors (device, patient, anatomy, procedure, and history). To reduce further revascularization, a tailor-made strategy may be considered in accordance with the factors and characteristics of the individual ISR lesion.

Mechanism of in-stent restenosis after second-generation drug-eluting stents (DES): is it different from bare-metal stents and first-generation DES?

First-generation drug-eluting stents (DES) have dramatically reduced the rate of in-stent restenosis (ISR) and subsequent target lesion revascularization (TLR) compared with bare-metal stents (BMS) (1). However, widespread use of first-generation DES has drawn attention to several unresolved, clinically relevant issues such as late stent thrombosis (ST) and late restenosis (2). Histopathological studies of first-generation DES have revealed that a chronic reaction to components of the permanent polymer reaction may lead to the delayed arterial healing, which is associated with increased risks of late DES failure (3,4). In addition, neoatherosclerosis is suggested as another cause of very late ST and late TLR (5). To overcome these limitations, biocompatible and biodegradable polymers have been developed and equipped with second-generation DES. Recent clinical trials demonstrated that second-generation DES has the improved efficacy and safety compared with those of first-generation DES (6,7). Nevertheless, second-generation DES, as well as first-generation DES, are not immune to ISR. In fact, Cassese et al. reported a large cohort of patients with angiographic surveillance that ISR rate of second-generation DES remains higher than 10% (8). Therefore, it is important to elucidate the mechanism of ISR after second-generation DES compared with that of BMS and first-generation DES, which may play a crucial role in the newly developed DES.

Meta-analysis of percutaneous transluminal atherectomy in the treatment for in-stent restenosis of lower extremity peripheral artery disease

To evaluate the clinical safety and efficacy of percutaneous transluminal atherectomy for in-stent restenosis (ISR) in patients with low extremity peripheral arterial diseases (PAD). PubMed, Elsevier, EBSCO, Spring databases and Cochrane Library were searched for relevant articles. Based on the different mechanisms of atherectomy, the patients were divided into mechanic atherectomy group and laser atherectomy group. The safety end points included the rate of distal embolism and severe arterial wall injuries. And the efficacy end points included primary patency rate and freedom from target vessel revascularization (TVR-free) 6 months and 12 months after surgery. A total of 9 studies and 620 patients (published between 2006 and 2014) were accepted. The rate of distal embolism was 4.2% (95% confidence interval (CI): 1.7%-6.7%), while that of severe arterial wall injuries was 1.9% (95%CI: 0.9%-3.0%), respectively. Laser atherectomy was responsible for more distal embolism (6.8%) compared to mechanic atherectomy (2.0%), which was significantly different (Q=21.66, P=0.010). At 6-month follow-up, primary patency rate and rate of TVR-free were 63.0% (95% CI: 55.5%-70.6%) and 80.4% (95% CI: 70.5%-90.3%), while at 12-month follow-up were 43.5% (95%CI: 32.2%-54.9%) and 58.0% (95% CI: 52.1%-63.9%), respectively. The free-TVR rate at 6 months follow-up in mechanical atherectomy group was 77.9%, and was inferior to that in laser atherectomy group (80.8%, Q=13.49, P=0.009). Published bias was discovered at the analysis of 12-month TVR-free rate by means of Begg Test (P=0.039). Meta analysis concerned about the 3 randomized controlled trials demonstrated that there was no significant improvement using atherectomy for ISR comparing to standard balloon at 6-month TVR-free rate (OR=1.34, 95% CI: 0.86-2.07, P=0.196). To treat ISR lesion in lower extremities, laser atherectomy has a lower free-TVR rate in the middle term follow-up.A higher rate of distal embolism is noted though. On balance, percutaneous transluminal atherectomy demonstrates no significant improvement compared to plain balloon angioplasty for ISR lesions.

One-year outcomes following drug-eluting balloon use for coronary ostial restenosis

AimsThe management of ostial lesions is one of the challenges of percutaneous coronary intervention (PCI) in recent medicine. Although stent implantation has increased the accuracy of the results and improved long-term outcomes, in-stent restenosis (ISR) occurs more frequency following the treatment of ostial lesions than the treatment of non-ostial lesions. When additional stenting is not desirable, PCI with drug-eluting balloons (DEBs) has emerged as an adjunctive strategy. However, little data regarding the effects of DEBs in ostial ISR lesions are available. Our study aimed to assess the efficacy of the use of DEBs in coronary ostial instent restenotic lesions. Methods and resultsFrom November of 2011 to May of 2014, 85 patients were diagnosed with coronary ostial ISR in our hospital. A total of 93 coronary ostial ISR lesions were treated with DEBs. More than half of the study patients had comorbidities, including hypertension, diabetes, and hyperlipidemia, 77.6% of the study patients had triple vessel coronary artery disease, and 54.1% of the study patients had left main coronary artery disease. In our study, target lesion revascularization were performed in 19.2% in all groups; 11.5% were in the ostial left anterior descending artery, 29.0% were in the ostial left circumflex artery, and 21.4% were in the ostial right coronary artery. Across all of the groups, 24.4% of the patients experienced major adverse cardiac cerebral events. ConclusionPercutaneous coronary intervention with drug-eluting balloons is an alternative strategy for coronary ostial instent restenosis when additional stenting is not desirable.

Abstract 17436: Ten-year Clinical Outcomes After the First Sirolimus-eluting Stent Implantation: Impact of In-stent Restenosis Lesion

Background: Little is known about the clinical follow-up after sirolimus-eluting stent (SES) implantation and about the effect of SES implantation in in-stent restenosis (ISR) lesion more than five years. We aimed to compare clinical outcomes up to 10 years after SES implantation in de novo lesion and ISR lesion. Methods: A series of 392 patients underwent the first SES implantation between November 2002 and December 2004, whose clinical outcomes were investigated. There were 253 patients for de novo lesion and 139 patients for ISR lesion. We evaluated the outcomes from the SES implantation to five years and beyond five years. Clinical information was obtained either from a review of the hospital records or by telephone interviews with the patients, family members, or primary care physicians. Results: Mean follow up period was 10.0 years. Cumulative incidence of major cardiac events (MACE) and target-lesion revascularization in ISR group were significantly higher than that in de novo group through 10 years (56.1% vs. 38.7%; p = 0.01, and 41.3% vs. 20.6%; p = 0.004, respectively) and the difference of the MACE and TLR rate in two groups increased in this period. Cumulative incidence of myocardial infarction (MI) and stent thrombosis (ST) between 2 groups were not significantly different (13.0% vs. 7.9%; p = 0.1, and 5.0% vs. 2.4%; p = 0.15, respectively). Conclusion: The incidence of MACE and TLR after the SES implantation in ISR lesion was significantly higher than that in de novo lesion and the difference of the TLR rate between in two lesions became more clear through 10 years, although the incidence of MI and ST had no significant difference in 2 groups.

Abstract 12908: Effects of Metabolic Syndrome on In-Stent Restenosis After PCI: Obesity Paradox and Sex-Associated Differences

Background: The impact of metabolic syndrome (MetS) on the efficacy of PCI remains controversial. Hypothesis: This controversy may be due in part to a positive influence of obesity (the “obesity paradox”) among the factors included in the definition of MetS. Fat distribution also varies by sex, possibly confounding the impact of obesity. Methods: To elucidate the possible effects of obesity in MetS patients on in-stent restenosis (ISR) or target lesion revascularization (TLR), 546 patients treated with coronary stents (BMS or DES) were stratified according to the presence of MetS with or without obesity, using NCEP-ATP III guidelines. Waist circumference or BMI (in patients without waist circumference data) was used for diagnosis of obesity. Follow-up angiography was scheduled 8 to 9 months after PCI to obtain ISR, which was defined as %diameter stenosis (%DS)>50%. Results: Mean age of the subjects was 70.5±9.8 years, and 32.1% were female. By standard criteria, 286 patients (52.4%) were diagnosed as MetS, and 320 patients (58.6%) met criteria for obesity. Among MetS patients, 61 patients (21.3% of MetS patients) were categorized as non-obesity. At 8 to 9 months follow-up, % DS, ISR rates, and TLR rates had trends to be higher in MetS than no-MetS (ISR; 26.6% in MetS, 20.0% in non-MetS, p=0.085). These parameters showed no difference between obesity and non-obesity (ISR; 23.8% in obesity, 23.0% in non- obesity, p=0.918, TLR; 14.1% in obesity, 15.0% in non-obesity, p=0.805). In patients with MetS (Figure), however, the ratio of %DS and ISR were significantly greater in the absence of obesity in female patients, whereas no difference was observed in male patients. In multivariate analysis, non-obesity was an independent predictor for ISR or TLR in female patients with MetS. Conclusions: Overall, obesity was not related to ISR or TLR after PCI. In female MetS patients, however, comorbidity of obesity appeared to be paradoxically protective.

Intravascular ultrasound as an adjunct tool for angiographically intermediate lesions and complex coronary interventions: patient selection and perspectives

Intravascular ultrasound as an adjunct tool for angiographically intermediate lesions and complex coronary interventions: patient selection and perspectives Eui Im,1 Jung-Sun Kim,2,3 Myeong-Ki Hong2–4 1Division of Cardiology, Yongin Severance Hospital, Yonsei University Health System, Yongin, 2Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, 3Cardiovascular Research Institute, 4Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea Abstract: Intravascular ultrasound (IVUS) provides valuable anatomic information about the coronary arterial lumen, wall, and plaques that cannot be assessed by coronary angiography alone. For over 2 decades, IVUS has been shown to be a helpful tool for identifying significant ischemia in angiographically intermediate left main (LM) or non-LM lesions by measuring the minimum luminal area. It can also guide percutaneous coronary intervention (PCI) in complex coronary lesions such as LM, bifurcation, chronic total occlusion, in-stent restenosis, and long or calcified lesions. In these complex lesions, IVUS can reduce stent thrombosis or restenosis by accurate lesion assessment and detection of stent underexpansion, malapposition, or edge dissections. Through further intervention based on these IVUS findings, optimal stent deployment can be achieved. IVUS can also identify the culprit lesion with plaque rupture, and vulnerable lesions with a large plaque burden or thin-cap fibroatheroma. Although other new imaging modalities with improved resolution and technologies are attracting increased clinical attention, IVUS remains the most reliable intracoronary imaging modality to guide PCI until other new imaging devices are proven to be useful and improve clinical outcomes. However, current data on clinical utility are conflicting and the guidelines do not recommend routine use of IVUS when performing angiography or PCI. In this review, we focus on issues related to the selection of patients who might benefit from IVUS guidance and discuss future perspectives on intracoronary imaging. Keywords: intravascular ultrasound, angiography, coronary artery disease

Paclitaxel-Eluting Balloon vs Standard Angioplasty to Reduce Restenosis in Diabetic Patients With In-Stent Restenosis of the Superficial Femoral and Proximal Popliteal Arteries

Purpose: To report the 3-year safety and effectiveness outcomes from the prospective all-comers DEBATE-ISR study (ClinicalTrials.gov identifier NCT01558531) of symptomatic diabetic patients with femoropopliteal in-stent restenosis (ISR) undergoing treatment with paclitaxel-eluting balloons compared with historical diabetic controls. Methods: From January 2010 to December 2011, 44 consecutive diabetic patients (mean age 74±11 years; 32 men) were treated with drug-eluting balloons (DEBs) and enrolled in the study. The control group comprised 42 consecutive diabetic patients (age 76±7 years; 23 men) treated with conventional balloon angioplasty (BA) from 2008 to 2009. Results: No significant differences in terms of clinical, angiographic, or procedural characteristics were observed between the study groups. Critical limb ischemia was present in the majority of patients. Tosaka class III ISR was observed in more than half of the patients. Mean lesion length was 132±86 and 137±82 mm in the DEB and BA groups, respectively (p=0.7). At 3-year follow-up, the rate of target lesion revascularization (TLR) was 40% in the DEB group vs 43% in the BA group (p=0.8); Kaplan-Meier analysis showed no significant differences in terms of freedom from TLR. The presence of a Tosaka class III occlusion was associated with a worse outcome in both study groups (odds ratio 3.96, 95% confidence interval 1.55 to 10.1, p=0.004). Conclusion: Using DEBs for femoropopliteal ISR yielded similar results to BA in terms of TLR at 3-year follow-up. The treatment of more complex ISR lesions was associated with an increased rate of TLR, irrespective of the technology used.

TCT-592 Ten-year Clinical Outcomes After The First Sirolimus-eluting Stent Implantation: Impact of In-stent Restenosis Lesion

Little is known about the clinical follow-up after sirolimus-eluting stent (SES) implantation and about the effect of SES implantation in in-stent restenosis (ISR) lesion more than five years. We aimed to compare clinical outcomes up to 10 years after SES implantation in de novo lesion and ISR

TCT-798 Stent Graft Treatment For Instent-Restenosis And De novo Lesions Associated With Very High Rates Of Failure In Infra-Inguinal Arterial Disease

Stent graft placement for femoro-popliteal arterial obstructive disease is an FDA approved indication for the Gore Viabahn (WL Gore, Flagstaff, AZ, USA) stent, for both denovo and instent restenosis (ISRS) lesions. To date there is little data on Viabahn stent graft outcomes in patients with De novo

TCT-504 Bioresorbable Scaffold As Option For The Treatment Of Coronary In-Stent Restenosis: Result From Single-Centre Prospective Observational Study With Angiographic Follow-Up

The aim of this single center observational study was to investigate the feasibility of bioresorbable vascular scaffold (BVS) in treatment in-stent restenosis lesions. In stent restenosis is still a relatively common problem in daily practice. Existing solutions were not fully effective so far. The

TCT-406 The Predictors of Instent Restenosis Again After Drug Eluting Balloon

Percutaneous coronary intervention (PCI) with drug-eluting balloons (DEB) has emerged as an adjunctive treatment for instent restenosis lesion. When compared to drug-eluting stents (DES), DEBs offer advantages such as immediate and homogeneous drug release in the arterial wall, absence of polymers

A novel drug‐coated scoring balloon for the treatment of coronary in‐stent restenosis: Results from the multi‐center randomized controlled PATENT‐C first in human trial

Scoring balloons produce excellent acute results in the treatment of in-stent restenosis (ISR), fibro-calcific and bifurcation lesions but have not been shown to affect the restenosis rate. A novel paclitaxel-coated scoring balloon (SB) was developed and tested to overcome this limitation. SB were coated with paclitaxel admixed with a specific excipient. Patients at four clinical sites in Germany and one in Brazil with ISR of coronary bare metal stent (BMS) were randomized 1:1 to treatment with either a drug-coated or uncoated SB. Baseline and 6-month follow-up quantitative coronary angiography was performed by an independent blinded core lab and all patients will be evaluated clinically for up to one year. The primary endpoint was angiographic in-segment late lumen loss (LLL). Secondary endpoints included the rate of clinically driven target lesion revascularization (TLR), composite of major adverse cardiovascular events (MACE), stent thrombosis and other variables. Sixty-one patients were randomized (28 uncoated and 33 drug-coated SB); mean age 65 years, males 72%, and presence of diabetes 39%. At 6-month angiography, in-segment LLL was 0.48 ± 0.51 mm in the uncoated SB group versus 0.17 ± 0.40 mm in the drug-coated SB group (P = 0.01; ITT analysis). The rate of binary restenosis was 41% in the uncoated SB group versus 7% in the drug-coated SB group (P = 0.004). The MACE rate was 32% with the uncoated SB vs. 6% in the drug-coated SB group (P = 0.016). This difference was primarily due to the reduced need for clinically driven TLR in the coated SB group (3% vs. 32% P = 0.004). A novel paclitaxel-coated coronary SB has been developed and successfully used in a first-in-human randomized controlled trial [ClinicalTrials.gov Identifier: NCT01495533]. © 2015 Wiley Periodicals, Inc.

Mechanisms and Patterns of Intravascular Ultrasound In-Stent Restenosis Among Bare Metal Stents and First- and Second-Generation Drug-Eluting Stents

The most common causes of in-stent restenosis (ISR) are intimal hyperplasia and stent under expansion. The purpose of this study was to use intravascular ultrasound (IVUS) to compare the ISR mechanisms of bare metal stents (BMS), first-generation drug-eluting stents (DES), and second-generation DES. There were 298 ISR lesions including 52 BMS, 73 sirolimus-eluting stents, 52 paclitaxel-eluting stents, 16 zotarolimus-eluting stents, and 105 everolimus-eluting stent. Mean patient age was 66.6 ± 1.1years, 74.2% were men, and 48.3% had diabetes mellitus. BMS restenosis presented later (70.0 ± 66.7months) with more intimal hyperplasia compared with DES (BMS 58.6 ± 15.5%, first-generation DES 52.6 ± 20.9%, second-generation DES 48.2 ± 22.2%, p= 0.02). Although reference lumen areas were similar in BMS and first- and second-generation DES, restenotic DES were longer (BMS 21.8 ± 13.5mm, first-generation DES 29.4 ± 16.1mm, second-generation DES 32.1 ± 18.7mm, p= 0.003), and stent areas were smaller (BMS 7.2 ± 2.4mm(2), first-generation DES 6.1 ± 2.1mm(2), second-generation DES 5.7 ± 2.0mm(2), p <0.001). Stent fracture was seen only in DES (first-generation DES 7 [5.0%], second-generation DES 8 [7.4%], p=0.13). In conclusion, restenotic first- and second-generation DES were characterized by less neointimal hyperplasia, smaller stent areas, longer stent lengths, and more stent fractures than restenotic BMS.

Optimal threshold of postintervention minimum stent area to predict in-stent restenosis in small coronary arteries: An optical coherence tomography analysis.

The aim of this study was to determine the best threshold of postintervention minimum stent area (MSA) assessed by optical coherence tomography (OCT) to predict long-term in-stent restenosis (ISR) for 2.5 mm-diameter everolimus-eluting stents (EES). Percutaneous coronary intervention (PCI) for small coronary arteries remains challenging. Stent underexpansion is a strong predictor of late ISR. We performed a retrospective analysis of 69 lesions in 69 patients undergoing PCI with 2.5 mm-diameter stents using OCT for the assessment of postintervention MSA and subsequent 9-month angiographic follow-up. The rates of angiographic ISR and target lesion revascularization were 7.2% and 1.4%. The postintervention OCT-MSA of EES < 3.5 mm(2) for predicting ISR yielded a sensitivity of 80%, specificity of 71%, positive predictive value of 18%, and negative predictive value of 98%. There was a marginally significant trend between increasing MSA quartiles and decreasing ISR rate (P for trend = 0.07). Postintervention OCT-MSA of 3.5 mm(2) best predicted 9-month ISR following PCI with 2.5-mm-diameter EES. Further large, prospective, observational studies are warranted that validate this result. © 2015 Wiley Periodicals, Inc.

Atypical “vacuum” inside of neoatherosclerosis long term after DES implantation: Insights from optical coherence tomography

Percutaneous coronary intervention (PCI) with stenting is the most widely performed procedure for the treatment of symptomatic coronary artery disease [ [1] Serruys P.W. et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. Benestent Study Group. N. Engl. J. Med. 1994; 331: 489-495 Crossref PubMed Scopus (4365) Google Scholar ], and the technological developments of drug-eluting stents (DES) have reduced the rates of in-stent restenosis and target lesion revascularization of bare-metal stent [ 2 Morice M.C. et al. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N. Engl. J. Med. 2002; 346: 1773-1780 Crossref PubMed Scopus (3859) Google Scholar , 3 Fajadet J. et al. Maintenance of long-term clinical benefit with sirolimus-eluting coronary stents: three-year results of the RAVEL trial. Circulation. 2005; 111: 1040-1044 Crossref PubMed Scopus (216) Google Scholar , 4 Moses J. et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N. Engl. J. Med. 2003; 349: 1315-1323 Crossref PubMed Scopus (4060) Google Scholar , 5 Weiz G. et al. Five-year follow-up after sirolimus-eluting stent implantation: results of the SIRIUS (Sirolimus-Eluting Stent in De-Novo Native Coronary Lesions) trial. J. Am. Coll. Cardiol. 2009; 53: 1488-1497 Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar ]. Clinical and histological studies of DES have confirmed evidence that restenosis is the result of arterial damage with subsequent neointimal tissue proliferation, which was named as “late catch-up” phenomenon [ 6 Grube et al. TAXUS VI final 5-year results: a multicentre, randomised trial comparing polymer-based moderate-release paclitaxel-eluting stent with a bare metal stent for treatment of long, complex coronary artery lesions. EuroIntervention. 2009; 4: 572-577 Crossref PubMed Scopus (58) Google Scholar , 7 Nakazawa et al. Coronary responses and differential mechanisms of late stent thrombosis attributed to first-generation sirolimus- and paclitaxel-eluting stents. J. Am. Coll. Cardiol. 2011; 57: 390-398 Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar ]. The mechanisms behind this DES failure remain complex and multi-factorial. The atherosclerotic changes (neoatherosclerosis) of neointimal layer inside of a restenosis are now thought to be potential mechanisms of DES failure [ [8] Park S.J. et al. In-stent neoatherosclerosis: a final common pathway of late stent failure. J. Am. Coll. Cardiol. 2012; 59: 2051-2057 Abstract Full Text Full Text PDF PubMed Scopus (301) Google Scholar ]. The exact pathogenesis of neoatherosclerosis remains partially unknown, however Yonetsu et al. have shown that the risk factors such as stent >48 months old, DES, cigarette smoking and chronic kidney disease are strongly associated with the formation of neoatherosclerosis, whereas the use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers appears to be protective [ [9] Yonetsu et al. Predictors for neoatherosclerosis: a retrospective observational study from the optical coherence tomography registry. Circ. Cardiovasc. Imaging. 2012; 5: 660-666 Crossref PubMed Scopus (126) Google Scholar ]. We present a case of atypical “vacuum” inside neoatherosclerotic pattern of restenosis after DES implantation where the OCT was used to describe this new report of neoatherosclerosis and to demonstrate probable causes of it.

Laser Atherectomy for Treatment of Femoropopliteal In-Stent Restenosis

Purpose: To investigate if laser atherectomy with adjunctive balloon angioplasty can improve endovascular treatment outcomes for femoropopliteal in-stent restenosis (ISR). Methods: A dual center study included 135 symptomatic patients (mean age 71 years; 76 men) who underwent endovascular treatment of femoropopliteal ISR between 2006 and 2013. Of these, 54 (40%) were treated with laser atherectomy and the remaining 81 patients with balloon angioplasty alone. Angiographic images were reviewed for lesion morphology and characteristics, TransAtlantic InterSociety Consensus (TASC) II classification, and distal runoff. Class I ISR was defined as focal lesions ≤50 mm, class II ISR as lesions >50 mm, and class III ISR as stent total occlusion. Recurrent ISR was determined by a peak systolic velocity ratio >2.4 by duplex ultrasound. Results: Patients treated with laser atherectomy had longer mean ISR lesion length (222 vs 114 mm, p<0.001) and more class III ISR (69% vs 20%, p=0.001). There was no association between laser atherectomy and rates of recurrent restenosis or occlusion for patients with class I/II ISR, but there was a significantly lower rate of target lesion revascularization at 2 years among patients treated with laser atherectomy (14% vs 44%, p=0.05). In comparison, patients with class III ISR treated with laser atherectomy had lower rates of recurrent restenosis at 1 year (54% vs 91%, p=0.05) and 2 years (69% vs 100%, p=0.05). Patients with class III ISR treated with laser atherectomy also had lower rates of recurrent in-stent occlusion at 2-year follow-up (33% vs 71%, p=0.04). Conclusion: When used to treat complex ISR, including in-stent occlusions, laser atherectomy with adjunctive balloon angioplasty may be associated with improved patency.

Late Restenosis After Paclitaxel-Coated Balloon Angioplasty Occurs in Patients With Drug-Eluting Stent Restenosis

BackgroundThere are currently inadequate data on whether “late restenosis” occurs after paclitaxel-coated balloon (PCB) angioplasty for in-stent restenosis (ISR) lesions. ObjectivesTo evaluate the long-term safety and efficacy of PCB angioplasty, we investigated serial clinical and angiographic outcomes after PCB angioplasty for ISR lesions. MethodsBetween September 2008 and December 2012, PCB angioplasty was performed in 468 patients with 550 ISR lesions (bare-metal stent restenosis [BMS-ISR]: 114 lesions, drug-eluting stent restenosis [DES-ISR]: 436 lesions). Two serial angiographic follow-ups were routinely planned for the patients (at 6 and 18 months after the procedure). ResultsEarly follow-up (6 months) angiography was performed for 488 lesions (89%), and recurrent restenosis occurred in 13 lesions (13.0%) in the BMS-ISR group and in 82 lesions (21.1%) in the DES-ISR group. Target lesion revascularization was performed for 7 lesions (7.0%) in the BMS-ISR group and 54 lesions (13.9%) in the DES-ISR group. Late follow-up (18 months) angiography was performed for 377 (88%) of the remaining 427 lesions (excluding target lesion revascularization lesions), and late restenosis was found in 2 lesions (2.5%) in the BMS-ISR group and 50 lesions (16.8%) in the DES-ISR group. Delayed late lumen loss was significantly larger in the DES-ISR group. Previous stent size ≤2.5 mm, percentage diameter stenosis after the procedure, and in-stent occlusion lesion were independent predictors of early restenosis. DES-ISR, percentage diameter stenosis at early follow-up, and hemodialysis were independent predictors of late restenosis. ConclusionsLate restenosis occurs after PCB angioplasty for DES-ISR lesions.

Clinical and pathological characteristics of homogeneous and nonhomogeneous tissue of in-stent restenosis visualized by optical coherence tomography.

Although it is known that in-stent restenosis (ISR) patterns appear homogeneous or nonhomogeneous by optical coherence tomography (OCT), interpretations of the ISR inflammatory response, of the OCT image, and its pathological implications are unclear. The aim of this study was to use OCT to characterize ISR and its inflammatory index in patients after coronary stenting. OCT was performed at follow-up in 100 angiographic ISR lesions. ISR lesions were divided into two groups: (a) homogeneous (n=48) and (b) nonhomogeneous (n=52) image groups. We assessed the ISR images produced by OCT for tissue heterogeneity and neo-intimal hyperplasia using the normalized standard deviation of OCT signal-intensity (OCT-NSD) observed in neo-intimal hyperplasia tissue. In some patients with a nonhomogeneous OCT image, we collected pathological tissue. The prevalence of drug-eluting stents was 48% in the nonhomogeneous group and 29% in the homogeneous group (P=0.05). The OCT-NSD value in the nonhomogeneous group (0.223±0.019) was significantly higher than that in the homogeneous group (0.203±0.025; P<0.0001). Pathological tissue showed fibrin thrombi with infiltrating macrophage in 12 cases of nonhomogeneous ISR. The area under the receiver operating characteristic curve for the prediction of a nonhomogeneous image was 0.73 for OCT-NSD (95% confidence interval: 0.62-0.83: P<0.0001). The odds ratio for the prediction of a nonhomogeneous image was 3.47 (95% confidence interval: 1.18-10.2: P=0.02) for smoking by logistic regression analysis. Nonhomogeneous ISR visualized by OCT showed a high OCT-NSD value, which was a useful predictor for nonhomogeneous images. Moreover, the nonhomogeneous ISR image visualized by OCT may show chronic inflammation and fibrin thrombi.

TREATMENT TO ISR WITH A SIDE BRANCH IS ENOUGH IN SINGLE STENT WITHOUT KBT: A STUDY INCLUDING ASSESSMENT OF SIDE BRANCH BLOOD FLOW

In recent years, the use of drug-coated balloon (DCB) for in-stent restenosis (ISR) has become possible, and the use of DCB is recommended for ISR lesions at bifurcations. In this study we examined the long-term outcomes of single stent kissing balloon technique (KBT) and single stent without KBT