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In-Stent Restenosis: Pathophysiology and Treatment

  • Coronary Artery Disease (D Feldman and V Voudris, Section Editors)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

Management of in-stent restenosis (ISR) remains a clinical challenge after both bare metal stent and drug-eluting stent placement. Autopsy studies and intravascular imaging have augmented our understanding of the pathophysiology of ISR. The clinical presentation and symptoms vary considerably among patients from stable angina to unstable angina and acute myocardial infarction. Potential treatment strategies include plain old balloon angioplasty (POBA), rotational atherectomy, vascular brachytherapy (VBT), bare metal stents (BMS), drug-coated balloons (DCBs), and drug-eluting stent (DES) placement. The most efficacious therapy depends on patient and lesion characteristics, but drug-eluting stents and drug-coated balloons yield the most successful angiographic and clinical results. Here, we discuss the underlying pathology, risk factors, and clinical presentation of ISR while examining the evidence supporting the optimal interventional techniques for this commonly encountered clinical entity.

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Abbreviations

ACS:

Acute coronary syndrome

BMS:

Bare metal stent

BVS:

Bioabsorbable vascular scaffold

CBA:

Cutting balloon angioplasty

DAPT:

Dual-antiplatelet therapy

DES:

Drug-eluting stent

DCB:

Drug-coated balloon

DEB:

Drug-eluting balloon

EES:

Everolimus-eluting stents

FFR:

Fractional flow reserve

ISAR-DESIRE:

Sirolimus-eluting Stent or Paclitaxel-eluting Stent vs Balloon Angioplasty for Prevention of Recurrences in Patients with Coronary In-stent Restenosis: a Randomized Controlled Trial

ISAR DESIRE 3:

Paclitaxel-eluting Balloons, Paclitaxel-eluting Stents, and Balloon Angioplasty in Patients with Restenosis after Implantation of a Drug-eluting Stent

ISAR DESIRE 4:

Intracoronary Stenting and Angiographic Results: Optimizing Treatment of Drug Eluting Stent In-Stent Restenosis 4

ISR:

In-stent restenosis

IVUS:

Intravascular ultrasound

LDL:

Low-density lipoprotein

LOE:

Level of evidence

MI:

Myocardial infarction

OCT:

Optical coherence tomography

PCI:

Percutaneous coronary intervention

PEB:

Paclitaxel-eluting balloon

PEPCAD:

A Safety and Efficacy Study of Paclitaxel-Eluting Balloon to Paclitaxel-Eluting Stent

PES:

Paclitaxel-eluting stent

POBA:

Plain old balloon angioplasty

RA:

Rotational atherectomy

RIBS I:

Restenosis Intra-stent: Balloon Angioplasty Versus Elective Stenting

RIBS II:

The Restenosis Intrastent: Balloon Angioplasty Versus Elective Sirolimus-Eluting Stenting

RIBS IV:

Restenosis Intra-Stent of Drug-Eluting Stents: Drug-Eluting Balloon vs Everolimus-Eluting Stent

RIBS V:

Restenosis Intra-Stent of Bare Metal Stents: Paclitaxel-Eluting Balloon vs Everolimus-Eluting Stent

SES:

Sirolimus-eluting stents

SISR:

Five-year follow-up of the Sirolimus-Eluting Stents vs Vascular Brachytherapy for Bare Metal In-Stent Restenosis

ST:

Stent thrombosis

TLR:

Target lesion revascularization

TVR:

Target vessel revascularization

VBT:

Vascular brachytherapy

ZES:

Zotarolimus-eluting stents

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

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Authors and Affiliations

  1. Department of Medicine, Greenberg Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, 520 East 70th St, Starr 4, New York, NY, 10021, USA

    Patrick M. Looser MD, Luke K. Kim MD & Dmitriy N. Feldman MD

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Correspondence to Patrick M. Looser MD.

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Patrick M. Looser and Luke K. Kim each declare no potential conflicts of interest.

Dr. Feldman has served as a consultant/speakers’ bureau member for Eli Lilly, Daiichi-Sankyo, Pfizer, Bristol Myers Squibb, and Abbott Vascular. Dr. Feldman is a section editor for Current Treatment Options in Cardiovascular Medicine.

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Looser, P.M., Kim, L.K. & Feldman, D.N. In-Stent Restenosis: Pathophysiology and Treatment. Curr Treat Options Cardio Med 18, 10 (2016). https://doi.org/10.1007/s11936-015-0433-7

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