Restenosis of Drug-Eluting Stents: A New Classification System Based on Disease Mechanism to Guide Treatment and State-of-the-Art Review. [Review]

MedStar author(s):
Citation: Circulation: Cardiovascular Interventions. 12(8):e007023, 2019 08.PMID: 31345066Institution: MedStar Heart & Vascular InstituteForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Coronary Artery Disease/th [Therapy] | *Coronary Restenosis/th [Therapy] | *Drug-Eluting Stents | *Percutaneous Coronary Intervention/ae [Adverse Effects] | *Percutaneous Coronary Intervention/is [Instrumentation] | Clinical Decision-Making | Coronary Artery Disease/dg [Diagnostic Imaging] | Coronary Restenosis/dg [Diagnostic Imaging] | Coronary Restenosis/ep [Epidemiology] | Decision Support Techniques | Humans | Incidence | Patient Selection | Prosthesis Design | Retreatment | Risk Factors | Treatment OutcomeYear: 2019Local holdings: Available online from MWHC library: 2008 - presentISSN:
  • 1941-7640
Name of journal: Circulation. Cardiovascular interventionsAbstract: Despite on-going evolution and iteration of drug-eluting stent (DES) technology, the prevalence of in-stent restenosis (ISR) remains relatively unchanged, encompassing =10% of percutaneous coronary interventions. The mechanism of ISR is multifactorial, including biological, mechanical, patient, and operator-related factors. The main mechanical contributors are stent underexpansion or fracture, while biological factors include local inflammation leading to aggressive neointimal proliferation and late neoatherosclerosis. Intracoronary imaging is critical to identify the mechanism of ISR and tailor therapy accordingly. The presentation of DES-ISR is not benign and is challenging for optimal treatment. Among the proposed treatment modalities are scoring and high-pressure balloons, percutaneous coronary intervention with additional DES, atheroablative therapies by laser or mechanical atherectomy, drug-coated balloons, vascular brachytherapy, and surgical revascularization. We propose a new classification for ISR that differentiates among mechanical, biological, and mixed etiologies. Stratifying ISR by mechanism guides individualized treatment of DES-ISR to improve clinical outcomes. An algorithmic approach, guided by intracoronary imaging, for the treatment of DES-ISR, is recommended based on the specific cause of restenosis.All authors: Iantorno M, Shlofmitz E, Waksman ROriginally published: Circulation: Cardiovascular Interventions. 12(8):e007023, 2019 Aug.Fiscal year: FY2020Digital Object Identifier: Date added to catalog: 2019-08-23
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Journal Article MedStar Authors Catalog Article 31345066 Available 31345066

Available online from MWHC library: 2008 - present

Despite on-going evolution and iteration of drug-eluting stent (DES) technology, the prevalence of in-stent restenosis (ISR) remains relatively unchanged, encompassing =10% of percutaneous coronary interventions. The mechanism of ISR is multifactorial, including biological, mechanical, patient, and operator-related factors. The main mechanical contributors are stent underexpansion or fracture, while biological factors include local inflammation leading to aggressive neointimal proliferation and late neoatherosclerosis. Intracoronary imaging is critical to identify the mechanism of ISR and tailor therapy accordingly. The presentation of DES-ISR is not benign and is challenging for optimal treatment. Among the proposed treatment modalities are scoring and high-pressure balloons, percutaneous coronary intervention with additional DES, atheroablative therapies by laser or mechanical atherectomy, drug-coated balloons, vascular brachytherapy, and surgical revascularization. We propose a new classification for ISR that differentiates among mechanical, biological, and mixed etiologies. Stratifying ISR by mechanism guides individualized treatment of DES-ISR to improve clinical outcomes. An algorithmic approach, guided by intracoronary imaging, for the treatment of DES-ISR, is recommended based on the specific cause of restenosis.

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