Stent Restenosis
ABSTRACT & COMMENTARY
Synopsis: In-stent balloon angioplasty is a highly successful treatment for stent restenosis (95% initial success) with a low long-term clinical event rate.
Source: Reimers B, et al. J Am Coll Cardiol 1997; 30:186-192.
Despite reduced rates of restenosis with stents, it still occurs in 15-35% of cases. Thus, Reimers and colleagues report their experience with repeat percutaneous procedures in stent restenosis. Among 130 patients with successful stent implantation and angiographic restenosis more than one month later, repeat percutaneous procedures were unsuccessful in six patients who were excluded. The study population of 124 patients (127 vessels) with successful repeat procedure for stent restenosis was followed for at least nine months. Plain old balloon angioplasty (POBA) with high inflation pressures was used in most cases (85%). Additional stents were implanted for inadequate results or adjacent dissection (13 vessels). Rotational atherectomy was used in four vessels and laser in two vessels. Most of the original stents were Palmaz-Schatz (83%), and 62% of the restenosis was focal (< 10 mm) in the body of the stent. Ninety percent of the restenosis cases had recurrent angina.
During the nine- to 66-month follow-up, 20% of the patients had the following events: death (2%), myocardial infarction (1%), bypass surgery (4%), repeat angioplasty (7%), and angina (6%); those who developed angina were medically treated. Events were more common in those treated with atherectomy and laser but were no different in those treated with POBA and restenting (20% and 15%). Multivariate predictors of events were saphenous vein graft lesions, low ejection fraction, multivessel disease, and short interval from original stent implantation to restenosis (< 3 months). Reimers et al conclude that in-stent balloon angioplasty is a highly successful treatment for stent restenosis (95% initial success) with a low long-term clinical event rate.
COMMENT BY MICHAEL H. CRAWFORD, MD
Stent restenosis is always disappointing, since stents are considered our best procedure for percutaneous coronary revascularization. The concept of internal hyperplasia protruding through the stent struts suggests that a debulking procedure such as atherectomy should be the preferred approach rather than just compressing this mass with another balloon inflation. However, in this study where POBA was the main treatment, short- and long-term results were good. They observed an event- free survival rate of 86% at one year, 80% at two years, and 74% at three years. The few patients treated with atherectomy or laser in this study seemed to have higher subsequent event rate, but the numbers were too small for definitive conclusions. The notion that in-stent POBA resulted in further stent expansion was not supported by their data. They mainly used repeat stenting for lesions adjacent to the original stent, and the results were good in this subgroup.
The initial results of POBA for stent restenosis in this study are similar to other reports, but this is the first study with long-term follow-up data. New therapies for stent restenosis could be compared to these data, since it is unlikely that randomized control trials of this issue will ever be done. There are some limitations to this study. First, it is retrospective and observational. More importantly, it is a clinically based study. Most of the patients had recurrent symptoms, and only a few underwent routine repeat angiography. Thus, the true incidence of stent restenosis is not known, and the results of POBA in all stent restenosis cases cannot be determined. Regardless, the results are useful for clinicians faced with symptomatic patients with stent restenosis.
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