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Mechanismen und Therapiekonzepte der Stentrestenose

Mechanisms and therapeutic concepts of restenosis after stent implantation

  • Interventionelle Kardiologie 1997—Perspektiven für die Zukunft
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Zusammenfassung

Die Stentrestenose hat sich in den letzten Jahren zu einem relevanten Problem der interventioneilen Kardiologie entwickelt, vor allem infolge der zunehmenden Implantations-frequenz sowie der Ausweitung der Implantationsindikationen. Die Restenoserate wird aufgrund dieser Umstände deutlich über den zuvor kalkulierten Ergebnissen der Benestent- und STRESS-Studie erwartet. Morphologisch ist die Stentrestenose charakterisiert durch eine frühe Aktivierung glatter Muskelzellen, die nach einigen Wochen großteilig durch extrazelluläre Matrix ersetzt wird.

Klinische, angiographische und intravaskuläre Ultraschalluntersuchungen haben eine Vielzahl von Prädiktoren der Stentrestenose identifiziert: Diabetes mellitus, Therapie von Restenosen, Implantation multipler Stents, kleine, kalzifizierte Gefäße, venöse Bypass-Gefäße, Ostium- und Y-Stenosen und komplexe Stenosemorphologie.

Standardtherapie der Stentrestenose ist derzeit die Ballondilatation. Bei kurzen, fokalen Stenosen (<10 mm) sind die Ergebnisse der einfachen PTCA befriedigend mit Restenoseraten zwischen 15 und 35%. Die Intervention ist in der Regel sicher mit nur geringen Begleitkomplikationen. Bei langstreckigen, diffusen Stentrestenosen (≥10 mm) führt die PTCA zu einer hohen Re-Restenoserate von bis zu>80%. Guer werden Vorteile von sogenannten „Debulking-Techniken” erwartet: direktionelle Koronaratherektomie (DCA), Excimer-Laserangioplastie (ELCA) oder Rotablation. Alle Debulking-Techniken gehen mit einer deutlichen Reduktion der Neointima innerhaib des Stents einher und erzielen in Kombination mit Ballondilatation größere postinterventionelle Lumendurchmesser. Ergebnisse über die Re-Restenoserate nach Anwendung dieser Techniken liegen nur sehrbegrenzt vor. Randomisiert kontrollierte Untersuchungen zum Vergleich mit Ballondilatation gibt es bisher nicht. Drei randomisierte multizentrische Studien laufen (LARS, ARTIST und TWISTER). um den Effekt von ELCA und Rotablation versus PTCA bei diffusen Stentrestenosen zu überprüfen.

Die medikamentöse Begleittherapie nach Behandlung von Stentrestenosen ist im wesentlichen auf die Gabe von ASS beschränkt, eine klare Indikation für Ticlopidin besteht derzeit nicht, positive Einflüsse werden langfristig von einer lokalen Bestrahlungstherapie (emittierende Stents oder Afterloading) erwartet.

Mit weiter steigenden Stentimplantationsraten und Implantationsindikationen wird bei einer niedrig kalkulierten Restenoserate von 20% für 1997 mit bis zu 80 000 Stentrestenosen gerechnet. Endgültige Empfehlungen für eine optimale Therapie dieser Patienten liegen bislang nicht vor.

Summary

Demonstration of a reduced restenosis rate after stent implantation (Benestent, STRESS) has initiated rapid increase in stent implantation rates with widening indications. At present, the majority of stents are implanted in “none-Benestent/STRESS-lesions” with the consequence of a higher restenosis rate as previously expected. Stent restenosis has therefore become a relevant problem in interventional cardiology. In contrast to balloon angioplasty, where acute and subacute recoil represents the major mechanism of restenosis, stent restenosis is exclusively attributed to neointima proliferation. Morphological studies have demonstrated that neointima is caused by early smooth muscle cell ingrowth with a maximum after 7 days which is then gradually replaced by extracellular matrix. Systematic clinical, angiographic and intravascular ultrasound studies have identified several risk factors for increased stent restenosis such as: diabetes mellitus, treatment of restenosis, serial stent implantation, small and calcified vessels, ostial lesions, venous bypass grafts and complex stenosis morphology. In addition, there is increasing evidence that aggressive implantation techniques with high pressures and oversized balloons may also induce higher restenosis rates.

Optimal treatment of instent restenosis has not been determined so far. Balloon angioplasty is at present considered the therapeutic option of choice. Several small studies have shown, that in short, discrete lesions (<10 mm) results of simple PTCA are acceptable with re-restenosis rates between 15 and 35%. The intervention is considered safe with low complication rates. In 10 to 15% additional stent implantation is necessary, usually due to dissections proximal or distal to the treated stent. In long, diffuse stent restenosis (≧10 mm), however, PTCA results in high re-restenosis rates up to >80%. This is most likely due to insufficient early balloon angioplasty results with minimal luminal diameters (MLD) significantly below the previous stent diameter. Therefore, debulking techniques have been used to reduce neointima burden within the stent. At present 3 techniques are available: directional coronary atherectomy (DCA), Excimerlaser angioplasty (ELCA) or high frequency rotablation. All of these techniques achieve a significant reduction in plaque volume within the stent and in combination with balloon angioplasty allow larger MLDs than PTCA alone. Limited experiences with ELCA and rotablation have shown that the techniques are safe without major periinterventional complications. DCA, however, has been accompanied with stent destruction and therefore should be considered with large care, especially in stents with coil design. At present, no randomized controlled trials for the comparison of debulking techniques with or without balloon angioplasty versus balloon angioplasty alone are available. Three multicenter trials have been initiated (LARS, ARTIST and TWISTER) to compare debulking techniques versus balloon angioplasty in diffuse stent restenosis.

Adjunct medical treatment after interventions for stent restenosis is usually limited to ASS alone, indications for additional application of Ticlopidine have not been verified so far. Positive results are expected for the use of local radiation therapy either by radioactive stent implantation or afterloading techniques.

With increasing stent implantation rates and indications, about 400 000 stents will be implanted in 1997 worldwide. Considering a low restenosis rate of 20%, 80 000 stent restenosis will occur within one year. Final recommendations for optimal treatment of these patients are not yet available.

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Literatur

  1. Abizaid A, Mehran R, Bucher T, et al. Does diabetes influence clinical recurrence after coronary stent implantation? J Am Coll Cardiol 1997;29:188A.

    Google Scholar 

  2. Anderson PG, Bajaj RK, Baxley WA, Roubin GS. Vascular pathology of balloon expandable flexible coil stents in humans. J Am Coll Cardiol 1992;19:372–81.

    PubMed  CAS  Google Scholar 

  3. Asakura M, Ueda Y, Hirayama A, et al. Neointima covering stent became thinner and transparent at 3 years follow-up: serial angioscopic and angiographic observations. Circulation 1996;94:I-454.

    Google Scholar 

  4. Baim DS, Levine MJ, Leon MB, Levine S, Ellis SG, Schatz RA. Management of restenosis within the Palmaz-Schatz coronary stent (the US Multicenter experience). Am J Cardiol 1993;71:364–6.

    Article  PubMed  CAS  Google Scholar 

  5. Bottner RK, Hardigan KR. High-speed rotational ablation for In-stent restenosis. Cathet Cardiovasc Diagn 1997;40:144–9.

    Article  PubMed  CAS  Google Scholar 

  6. Bowerman RE, Pinkerton CA, Kirk B, Waller BF. Disruption of a coronary stent during atherectomy for restenosis. Cather Cardiovasc Diagn 1991;24:248–51.

    Article  CAS  Google Scholar 

  7. Buchbinder M, Goldberg SL, Fotuna R, et al. Rotational atherectomy for treatment of intra-stent restenosis: initial experience. Circulation 1996;94:I-621.

    Google Scholar 

  8. Carter AJ, Laird JR, Farb A, Kufs W, Wortham DC, Virmani R. Morphologic characteristics of lesion formation and time course of smooth muscle cell proliferation in a porcine proliferation restenosis model. J Am Coll Cardiol 1994;24:1398–405.

    PubMed  CAS  Google Scholar 

  9. Carter AJ, Laird JR, Hoopes TG, et al. Histology after placement of 3-particel emitting stents: insights into inhibition of neointimal formation. J Am Coll Cardiol 1996;27:198A.

    Article  Google Scholar 

  10. de Jaegere PP, van Domburg RT, de Feyter PJ, Ruygrok PN, van der Giessen WJ, van den Brand MJ, Serruys PW. Long-term clinical outcome after stent implantation in saphenous vein grafts. J Am Coll Cardiol 1996;28:89–96.

    Article  PubMed  Google Scholar 

  11. Dussaillant GR, Mintz GS, Pichard AD, et al. Effect of rotational atherectomy in noncalcified atherosclerotic plaque: a volumetric intravascular ultrasound study. J Am Coll Cardiol 1996;28:856–60.

    Article  PubMed  CAS  Google Scholar 

  12. Elezi S, Schühlen H, Hausleiter J, et al. Six-month angiographic follow-up after stenting of chronic total coronary occlusions. J Am Coll Cardiol 1997;29:16A.

    Google Scholar 

  13. Elezi S, Schühlen H, Wehinger A, et al. Stent placement in diabetic versus non-diabetic patients. Six-month angiographic followup. J Am Coll Cardiol 1997;29:188A.

    Google Scholar 

  14. Eltchaninov H, Cribier A, Koning C, Tron C, Letac B. Balloon angioplasty for in-stent restenosis: immediate and 6-month clinical and angiographic results. Eur Heart J 1997;84:498A.

    Google Scholar 

  15. Erbel R, Haude M, Höpp HW et al. REstenosis STent (REST)-study: randomized trial comparing stenting and balloon angioplasty for treatment of restenosis after balloon angioplasty. J Am Coll Cardiol 1996;27:732–4.

    Google Scholar 

  16. Fenton SH, Fischman DL, Savage MP, et al. Long-term angiographic and clinical outcome after implantation of balloon-expandable stents in aorto-coronary saphenous vein grafts. Am J Cardiol 1994;74:1187–91.

    Article  PubMed  CAS  Google Scholar 

  17. Fernandez-Aviles F, Alonso JJ, Duran JM, et al. High pressure increases late loss after coronary stenting. J Am Coll Cardiol 1997;29:369A.

    Google Scholar 

  18. Fischman DL, Leon MD, Baim DS, et al. for the Stent Restenosis Study Investigators. A randomized comparison of coronary-stent placement and balloon angioplasty in treatment of coronary artery disease. N Engl J Med 1994;331:496–501.

    Article  PubMed  CAS  Google Scholar 

  19. Garcia-Cantu E, Spaulding C, Corcos T, et al. Stent implantation in acute myocardial infarction. Am J Cardiol 1996;77:451–4.

    Article  PubMed  CAS  Google Scholar 

  20. Gaxiola E, Vlietstra RE, Browne KF, et al. Six-month follow-up of patients with multiple stents in a single coronary artery. J Am Coll Cardiol 1997;29:276A.

    Google Scholar 

  21. Gordon PC, Gibson CM, Cohen DJ, Carozza JP, Kuntz RE, Baims DS Mechanisms of restenosis and redilation within coronary stents-Quantitative angiographic assessment. J Am Coll Cardiol 1993;21:1166–74.

    PubMed  CAS  Google Scholar 

  22. Haberbosch W, Hölschermann H, Bohle RM, et al. Directional coronary atherectomy for In-Stent restenosis: Clinical outcome and histopathology. J Invas Cardiol 1997;9:44C.

    Google Scholar 

  23. Hamasaki N, Nosaka H, Kimura T, Nakagawa Y, Yokoi H, Tamura T. Influence of lesion length on late angiographic outcome and restenotic process after successful stent implantation. J Am Coll Cardiol 1997;29:239A.

    Google Scholar 

  24. Hamm CW, Seabra-Gomes R, Bounier J, et al. on behalf of the LARS study group. Laser angioplasty of within-stent restenosis-results from the LARS surveillance study. Eur Heart J 1997;18:497.

    Google Scholar 

  25. Hausleiter J, Schuühlen H, Elezi S, et al. Impact of high inflation pressures on six-month angiographic follow-up after coronary stent placement. J Am Coll Cardiol 1997;29:369A.

    Google Scholar 

  26. Hermiller JB, Fry ET, Peters TF, et al. Late coronary artery stenosis regression within the Gianturco-Roubin intracoronary stent. Am J Cardiol 1996;77:247–51.

    Article  PubMed  CAS  Google Scholar 

  27. Hoffmann R, Mintz GS, Dussaillant GR, Popma JJ, Pichard AD, Satler LF, Kent KM, Griffin J, Leon MB Patterns and mechanisms of instent restenosis: A serial intravascular ultrasound study. Carculation 1996;94:1247–54.

    CAS  Google Scholar 

  28. Hoffmann R, Mintz GS, Popma JJ, et al. Intravascular ultrasound predictors of restenosis at the margins of Palmaz-Schatz stents. Am J Cardiol 1997;74:951–3.

    Article  Google Scholar 

  29. Hong MK, Kent KM, Mehran R, et al. Continuous subcutaneous angiopeptin treatment significantly reduces neointimal hyperplasia in a porcine coronary in-stent restenosis model. Circulation 1997;95:449–54.

    PubMed  CAS  Google Scholar 

  30. Hong MK, Kent KM, Satler LF, et al. Are long-term results different when stents are used in de novo versus restenotic lesion? Circulation 1996;94:1–331.

    Google Scholar 

  31. Hong MK, Satler LF, Kent KM, et al. Six-month results of debulking followed by immediate stent therapy for high risk saphenous vein graft lesions. J Am Coll Cardiol 1997;29:17A.

    Google Scholar 

  32. Hsu YS, Tamai H, Ueda K, et al. Efficacy of Tranilast on restenoisis after coronary stenting. Circulation 1996;94:1–620.

    Google Scholar 

  33. Kakuta T, Currier JW, Haudenchild CC, Ryan TJ, Faxon DP. Differences in compensatory vessel enlargement, not intimal formation, account for restenosis after angioplasty in the hypercholesterolemic rabbit model. Circulation 1994;89:2809–15.

    PubMed  CAS  Google Scholar 

  34. Kastrati A, Schömig A, Elezi S, et al. Predictive factors of restenosis after coronary stent placement. J Am Coll Cardiol (in press).

  35. Kearney M, Pieczek A, Haley L, et al. Histopathology of in-stent restenosis in patients with peripheral artery disease Circulation 1997;95:1998–2002.

    PubMed  CAS  Google Scholar 

  36. Kimura T, Yokoi H, Nakagawa Y, et al. Three-year follow-up after implantation of metallic coronary-artery stents. N Engl J Med 1996;334:561–6.

    Article  PubMed  CAS  Google Scholar 

  37. Kip KE, Faxon DP, Detre KM, Yeh W, Kelsey SF, Currier JW. Coronary angioplasty in diabetic patients. The National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry. Circulation 1996;94:1818–25.

    PubMed  CAS  Google Scholar 

  38. Klues HG, Reffelmann T, vom Dahl J, Hanrath P. High-speed rotational coronary atherectomy for the treatment of restenosis in coronary stents. J Am Coll Cardiol 1997;29:313A.

    Google Scholar 

  39. Klugherz BD, DeAngelo DL, Kim BK, Herrmann HC, Hirshfeld JW, Kolansky DM. Three-year clincal follow-up after Palmaz-Schatz stenting. J Am Coll Cardiol 1996;27:1185–91.

    Article  PubMed  CAS  Google Scholar 

  40. Kornowski R, Mintz GS, Mehran R, et al. The “Full Metal Jacket” procedural results and late clinical outcomes after placement of three or more coronary stents. J Am Coll Cardiol 1997;29:188A.

    Google Scholar 

  41. Kuntz RE, Gibson CM, Nobuyoshi M, et al. Generalised model of restenosis after conventional angioplasty, stenting and directional atherectomy. J Am Coll Cardiol 1993;21:15–25.

    Article  PubMed  CAS  Google Scholar 

  42. Laird JR, Carter AJ, Kufs WM, et al. Inhibition of neointimal proliferation with low-dose irradiation from a β-particel emitting stent. Circulation 1996;93:529–36.

    PubMed  CAS  Google Scholar 

  43. Lefevre T, Louvard Y, Morice MC, et al. In-stent restenosis: Should we stent the stent? A single center prospective study. J Invas Cardiol 1997;9:47C.

    Google Scholar 

  44. Margolis J, Bejarano J, Draz P. Laser approach for coronary artery or vein graft in-stent restenosis. Eur Heart J 1997;18:497.

    Google Scholar 

  45. Mehran R, Mintz GS, Bucher TA, et al. Aorto-ostial instent restenosis: mechanisms, treatment, and results: a serial quantitative angiographic and intravascular ultrasound study. Circulation 1996;94:I-200.

    Google Scholar 

  46. Mehran R, Mintz GS, Pichard AD, et al. Impact of vessel wall injury on in-stent restenosis: a serial quantitative angiographic and intravascular ultrasound study. Circulation 1996;94:I-262.

    Google Scholar 

  47. Mehran R, Mintz GS, Popma JJ, et al. Excimer laser angioplasty in the treatment of instent restenosis: an intravascular ultrasound study. J Am Coll Cardiol 1996;27:362A.

    Article  Google Scholar 

  48. Mehran R, Mintz GS, Popma JJ, et al. Mechanism and results of balloon angioplasty for the treatment of in-stent restenosis. Am J Cardiol 1996;78:618–22.

    Article  PubMed  CAS  Google Scholar 

  49. Meyer T, Schmidt T, Buchwald A, Wiegand V. Stent wire cutting during coronary directional atherectomy. Clin Cardiol 1993;16:450–2.

    Article  PubMed  CAS  Google Scholar 

  50. Mintz GS, Massullo V, Popma JJ, et al. Transcatheter Iridium-192 irradiation reduces in-stent neointimal tissue proliferation: a serial volumetric intravascular ultrasound analysis from the SCRIPPS trial. J Am Coll Cardiol 1997;29:60A.

    Google Scholar 

  51. Mintz GS, Popma JJ, Pichard AD, et al. Arterial remodeling after coronary angioplasty: a serial intravascular ultrasound study. Circulation 1996;94:35–43.

    PubMed  CAS  Google Scholar 

  52. Mintz GS, Potkin BN, Keren G, et al. Intravascular ultrasound evaluation of the effect of rotational atherectomy in obstructive atherosclerotic coronary artery disease. Circulation 1992;86:1383–93.

    PubMed  CAS  Google Scholar 

  53. Mittal S, Weiss DL, Hirshfeld JW, Kolansky DM, Herrmann HC. Restenotic lesions have a worse outcome after stenting. Circulation 1996;94:I-331.

    Google Scholar 

  54. Moris C, Alfonso F, Lambert JL, et al. Stenting for coronary dissection after balloon dilation of in-stent restenosis: Stenting a previously stented site. Am Heart J 1996;131:834–6.

    Article  PubMed  CAS  Google Scholar 

  55. Moussa I, Di Mario C, Moses J, Reimers B, Blengino S, Colombo A. The predictive value of different intravascular ultrasound criteria for restenosis after coronary stenting. J Am Coll Cardiol 1997;29:60A.

    Google Scholar 

  56. Mudra H, Regar E, Klauss V, et al. Serial follow-up after optimized ultrasound-guided deployment of Palmaz-Schatz stents. Circulation 1997;95:363–70.

    PubMed  CAS  Google Scholar 

  57. Nasser TK, Fry ETA, Peters TF, et al. Coronary stenting in women: clinical outcomes are equivalent to men. J Am Coll Cardiol 1997;29:71A.

    Google Scholar 

  58. O'Brien ER, Alpers CE, Stewart DK, et al. Proliferation in primary and restenotic coronary atherectomy tissue: implications for antiproliferative therapy. Circ Res 1993;73:223–31.

    PubMed  Google Scholar 

  59. Ozaki Y, Violaris AG, Nobuyoshi M, Yokoi H, Kobayashi T, Serruys P. Quantitative angiographic predictors of restenosis after the less shortening wallstent implantation. J Am Coll Cardiol 1997;29:240A.

    Google Scholar 

  60. Pathan A, Butte A, Harrell L, Ferrell M, Gold HK, Palacios I. Directional coronary atherectomy is superior to PTCA for the treatment of Palmaz-Schatz stent restenosis. J Am Coll Cardiol 1997;29:68A.

    Google Scholar 

  61. Pepine CJ, Holmes DR, Block PC, et al. Coronary artery stents: ACC Expert Consensus Document. J Am Coll Cardiol 1996;28:782–94.

    PubMed  CAS  Google Scholar 

  62. Piana RN, Moscucci M, Cohen DJ, et al. Palmaz-Schatz stenting for treatment of focal vein graft stenosis: immediate results and long-term outcome. J Am Coll Cardiol 1994;23:1296–304.

    Article  PubMed  CAS  Google Scholar 

  63. Reimers B, Moussa J, Akiyama T, et al. Long-term clinical follow-up after successful repeat percutaneous intervention for stent restenosis. J Am Coll Cardiol 1997;30:186–92.

    Article  PubMed  CAS  Google Scholar 

  64. Rivard A, Lecierc G, Bouchard M, et al. Low-dose b-emitting radioactive stents inhibit neointimal hyperplasia in porcine coronary arteries: an IVUS assessment. Circulation 1996;94:I-210.

    Google Scholar 

  65. Rogers C, Edelman ER. Endovascular stent design dictates experimental restenosis and thrombosis. Circulation 1995;91: 2995–3001.

    PubMed  CAS  Google Scholar 

  66. Savage MP, Douglas JS, Fishman DL, et al. for the Saphenous vein de novo trial investigators. Stent placement compared with balloon angioplasty for obstructed coronary bypass grafts. N Engl J Med 1997;337:740–7.

    Article  PubMed  CAS  Google Scholar 

  67. Schiele F, Meneveau N, Vuillemenot A, Gupta S, Bassand JP. Rotational atherectomy followed by balloon angioplasty for treatment of intra stent restenosis. A pilot study with quantitative angiography and intravascular ultrasound. J Am Coll Cardiol 1997;29:498.

    Article  Google Scholar 

  68. Schiele F, Meneveau N, Vuillemenot A, Gupta S, Zhang DD, Bassand JP. Intracoronary ultrasound assessment of balloon angioplasty in intrastent restenosis. J Am Coll Cardiol 1997;29:240A.

    Google Scholar 

  69. Schömig A, Neumann FJ, Kastriati A, et al. A randomized comparison of antiplateled and anticoagulant therapy after the placement of coronary artery stents. N Engl J Med 1996;334:1084–9.

    Article  PubMed  Google Scholar 

  70. Schömig A, Neumann FJ, Walter H, et al. Coronary stent placement in patients with acute myocardial infarction: comparison of clinical and angiographic outcome after randomization to antiplatelet or anticoagulation therapy. J Am Coll Cardiol 1997;29:28–34.

    Article  PubMed  Google Scholar 

  71. Schühlen H, Hadamitzky M, Walter H, Ulm K, Schömig A. Major benefit from antiplatelet therapy for patients at high risk for adverse cardiac events after coronary Palmaz-Schatz stent placement: analysis of a prospective risk stratification protocol in the Intracoronary Stenting and Antithrombotic Regimen (ISAR) trial. Circulation 1997;95:2015–21.

    PubMed  Google Scholar 

  72. Schühlen H, Hausleiter J, Elezi S, et al. Are ACC/AHA lesion characteristics predictors for late angiographic results after coronary stent placement? J Am Coll Cardiol 1997;29:239A.

    Google Scholar 

  73. Schühlen J, Hausleiter J, Elezi S, et al. Coronary stent placement in ostial lesions. Six-month clinical and angiographic follow-up. J Am Coll Cardiol 1997;29:16A.

    Google Scholar 

  74. Schwartz RS, Huber KC, Murphy JG, et al. Restenosis and the proportional neointimal response to coronary artery injury: results in a porcine model. J Am Coll Cardiol 1992;19:267–74.

    Article  PubMed  CAS  Google Scholar 

  75. Serruys PW, ed. Handbook of coronary stents. UK: M. Dunitz Publ., 1996.

    Google Scholar 

  76. Serruys PW, de Jaeger P, Kiemeneij F, et al. for the Benestent Study Group. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary heart disease. N Engl J Med 1994;331:489–95.

    Article  PubMed  CAS  Google Scholar 

  77. Sharma SK, Duvvuri S, Dangas G, et al. Rotational atherectomy for in-stent restenosis: acute and long-term results of first 100 cases. Eur Heart J 1997;84:497A.

    Google Scholar 

  78. Strauss BH, Umans VA, van Suylen RJ, et al. Directional atherectomy for treatment of restenosis within coronary stents: Clinical, angiographic and histology results. J Am Coll Cardiol 1992;20:1465–73.

    Article  PubMed  CAS  Google Scholar 

  79. Teirstein PS, Massullo V, Jani S, et al. Catheter-based radiotherapy to inhibit restenosis after coronary stenting. N Engl J Med 1997;336:1697–703.

    Article  PubMed  CAS  Google Scholar 

  80. The EPILOG Investigators. Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularisation. N Engl J Med 1997;336:1689–96.

    Article  Google Scholar 

  81. Tilli FV, Aliabadi D, Bowers T, Shoukfeh MM, Spybrook M, Sadian X. Optimal coronary stenting in diabetics: a viable percutaneous alternative to cardiac surgery. J Am Coll Cardiol 1997; 29:455A.

    Google Scholar 

  82. Vahdat B, Bonan R, Paiement P, Bilodeau L, Doucet S, Page D. Management of coronary in-stent restenosis by balloon angioplasty. Eur Heart J 1997;18:498A.

    Google Scholar 

  83. van Belle E, Bauters C, Hubert E, et al. Restenosis rates in diabetic patients. A comparison of coronary stenting and balloon angioplasty in native coronary arteries. Circulation 1997;96:1454–60.

    PubMed  Google Scholar 

  84. Wong SC, Popma JJ, Pichard AD, et al. Comparison of clinical and angiographic outcomes after saphenous vein graft angioplasty using coronary versus “biliary” tubular slotted stents. Circulation 1995;91:339–50.

    PubMed  CAS  Google Scholar 

  85. Yokoi H, Kimura T, Nakagawa Y, Nosaka H, Nobuyoshi M. Long-term clinical and quantitative angiographic follow-up after the Palmaz-Schatz stent restenosis. J Am Coll Cardiol 1996; 27:224A.

    Article  Google Scholar 

  86. Yokoi H, Nobuyoshi M, Nosaka H, et al. Palmaz-Schatz stent implantation in calcified lesions. Immediate and follow-up results. Circulation 1996;94:I-453.

    Google Scholar 

  87. Ziada KM, Kim MH, Potts W, et al. Predictors of target vessel revascularization following coronary stent deployment. J Am Coll Cardiol 1997;29:239A.

    Google Scholar 

  88. Ziada KM, Tuzcu EM, De Franco AC, et al. Absolute, not relative, post-stent lumen area is a better predictor of clinical outcome. Circulation 1996;94:I-453.

    Google Scholar 

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  1. Medizinische Klinik I, Universitätsklinikum der RWTH Aachen, Rauwelsstraße 30, D-52057, Aachen

    H. G. Klues, P. W. Radke, R. Hoffmann & J. vom Dahl

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Klues, H.G., Radke, P.W., Hoffmann, R. et al. Mechanismen und Therapiekonzepte der Stentrestenose. Herz 22, 322–334 (1997). https://doi.org/10.1007/BF03044283

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