Refractory In-Stent Restenosis: Improving Outcomes by Standardizing Our Approach
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Purpose of Review
This review will focus on our approach for the treatment of refractory in-stent restenosis.
The discovery of bare metal stents over three decades ago set a milestone in the evolution of percutaneous coronary intervention, which is currently the most widely performed procedure for the treatment of symptomatic coronary disease. However, the broad utilization of stents resulted in the new phenomenon of in-stent restenosis (ISR). Over the years, there has been an increase of the incidence of ISR despite continued improvement of drug-eluting stent (DES) technology. The mechanism of ISR is multifactorial, including biological, mechanical, patient, and operator-related factors. The most common factor is aggressive neointimal proliferation and neoatherosclerosis. ISR presentation is not benign, and treatment is challenging, especially in cases of DES-ISR.
We review available therapy modalities for ISR, including medical therapy, scoring balloons, atheroablative therapies, repeat DES, vascular brachytherapy, drug-coated balloons, and coronary artery bypass grafting.
KeywordsIn-stent restenosis Bare metal stent Drug-eluting stents Balloon angioplasty Drug-coated balloon
Compliance with Ethical Standards
Conflict of Interest
Ron Waksman: Advisory Board: Abbott Vascular, Amgen, Boston Scientific, Medtronic, Philips Volcano, Pi-Cardia Ltd., Cardioset. Consultant: Abbott Vascular, Amgen, Biosensors, Biotronik, Boston Scientific, Medtronic, Philips Volcano, Pi-Cardia Ltd., Cardioset; Grant Support: Abbott Vascular, AstraZeneca, Biosensors, Biotronik, Boston Scientific, Chiesi. Speakers Bureau: AstraZeneca, Chiesi; Investor: MedAlliance.
Micaela Iantorno has no conflicts to disclose.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
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