Review

Authors: Michael S Kim, Larry S Dean

The introduction of coronary stents marked a major turning point in the practice of interventional cardiology. Whereas the efficacy of balloon angioplasty was challenged both by immediate mechanical complications and by a high incidence of restenosis, coronary stents offered cardiologists a means by which to not only augment immediate procedural success, but also to reduce the incidence of restenosis following coronary intervention. However, despite technological advances and an improved understanding of the restenotic process, the overall rate of in-stent restenosis following bare metal stent implantation remains high. Although the introduction of drug-eluting stents has further reduced the incidence of restenosis, the "real-world" application of drug-eluting stents in increasingly complex lesion and patient subsets has given way to the even greater clinical challenge of managing drug-eluting stent restenosis. Although the standard treatment of bare metal stent restenosis typically involves placement of a drug-eluting stent, the optimal therapeutic approach to drug-eluting stent restenosis remains less defined. The issue of in-stent restenosis (especially following implantation of a drug-eluting stent) remains a clinical challenge, and investigation into therapeutic options remains ongoing. As technology evolves, such investigation will likely incorporate novel approaches including drug-coated balloons novel stent designs.

Topics: Coronary Restenosis; Drug-Eluting Stents; Humans; Randomized Controlled Trials as Topic; Risk Factors; Stents

PubMed: 20406239
DOI: 10.1111/j.1755-5922.2010.00155.x

Authors: Jae-Chan Ryu, Jae-Han Bae, Sang Hee Ha...

BACKGROUND

Prognosis after vertebrobasilar stenting (VBS) may differ from that after carotid artery stenting (CAS). Here, we directly compared the incidence and predictors of in-stent restenosis and stented-territory infarction after VBS and compared them with those of CAS.

METHODS

We enrolled patients who underwent VBS or CAS. Clinical variables and procedure-related factors were obtained. During the 3 years of follow-up, in-stent restenosis and infarction were investigated in each group. In-stent restenosis was defined as reduction in the lumen diameter > 50% compared with that after stenting. Factors associated with the occurrence of in-stent restenosis and stented-territory infarction in VBS and CAS were compared.

RESULTS

Among 417 stent insertions (93 VBS and 324 CAS), there was no statistical difference in in-stent restenosis between VBS and CAS (12.9% vs. 6.8%, P = 0.092). However, stented-territory infarction was more frequently observed in VBS than in CAS (22.6% vs. 10.8%; P = 0.006), especially a month after stent insertion. HbA1c level, clopidogrel resistance, and multiple stents in VBS and young age in CAS increased the risk of in-stent restenosis. Diabetes (3.82 [1.24-11.7]) and multiple stents (22.4 [2.4-206.4]) were associated with stented-territory infarction in VBS. However, in-stent restenosis (odds ratio: 15.1, 95% confidence interval: 3.17-72.2) was associated with stented-territory infarction in CAS.

CONCLUSIONS

Stented-territory infarction occurred more frequently in VBS, especially after the periprocedural period. In-stent restenosis was associated with stented-territory infarction after CAS, but not in VBS. The mechanism of stented-territory infarction after VBS may be different from that after CAS.

Topics: Humans; Carotid Stenosis; Stents; Coronary Restenosis; Carotid Arteries; Constriction, Pathologic; Infarction; Treatment Outcome; Recurrence; Risk Factors; Retrospective Studies

PubMed: 36803229
DOI: 10.1186/s12883-023-03110-z

Review

Authors: Grzegorz K Jakubiak, Natalia Pawlas, Grzegorz Cieślar...

Diabetes mellitus (DM) is a strong risk factor for the development of cardiovascular diseases such as coronary heart disease, cerebrovascular disease, and peripheral arterial disease (PAD). In the population of people living with DM, PAD is characterised by multi-level atherosclerotic lesions as well as greater involvement of the arteries below the knee. DM is also a factor that significantly increases the risk of lower limb amputation. Percutaneous balloon angioplasty with or without stent implantation is an important method of the treatment for atherosclerotic cardiovascular diseases, but restenosis is a factor limiting its long-term effectiveness. The pathogenesis of atherosclerosis in the course of DM differs slightly from that in the general population. In the population of people living with DM, more attention is drawn to such factors as inflammation, endothelial dysfunction, platelet dysfunction, blood rheological properties, hypercoagulability, and additional factors stimulating vascular smooth muscle cell proliferation. DM is a risk factor for restenosis. The purpose of this paper is to provide a review of the literature and to present the most important information on the current state of knowledge on mechanisms and the clinical significance of restenosis and in-stent restenosis in patients with DM, especially in association with the endovascular treatment of PAD. The role of such processes as inflammation, neointimal hyperplasia and neoatherosclerosis, allergy, resistance to antimitotic drugs used for coating stents and balloons, genetic factors, and technical and mechanical factors are discussed. The information on restenosis collected in this publication may be helpful in planning further research in this field, which may contribute to the formulation of more and more precise recommendations for the clinical practice.

Topics: Constriction, Pathologic; Coronary Restenosis; Diabetes Mellitus; Humans; Peripheral Arterial Disease; Stents

PubMed: 34831726
DOI: 10.3390/ijerph182211970

Review

Authors: Rui-Xing Yin, De-Zhai Yang, Jin-Zhen Wu...

Percutaneous coronary intervention (PCI) has become the most common revascularization procedure for coronary artery disease. The use of stents has reduced the rate of restenosis by preventing elastic recoil and negative remodeling. However, in-stent restenosis remains one of the major drawbacks of this procedure. Drug-eluting stents (DESs) have proven to be effective in reducing the risk of late restenosis, but the use of currently marketed DESs presents safety concerns, including the non-specificity of therapeutics, incomplete endothelialization leading to late thrombosis, the need for long-term anti-platelet agents, and local hypersensitivity to polymer delivery matrices. In addition, the current DESs lack the capacity for adjustment of the drug dose and release kinetics appropriate to the disease status of the treated vessel. The development of efficacious therapeutic strategies to prevent and inhibit restenosis after PCI is critical for the treatment of coronary artery disease. The administration of drugs using biodegradable polymer nanoparticles as carriers has generated immense interest due to their excellent biocompatibility and ability to facilitate prolonged drug release. Despite the potential benefits of nanoparticles as smart drug delivery and diagnostic systems, much research is still required to evaluate potential toxicity issues related to the chemical properties of nanoparticle materials, as well as to their size and shape. This review describes the molecular mechanism of coronary restenosis, the use of DESs, and progress in nanoparticle drug- or gene-eluting stents for the prevention and treatment of coronary restenosis.

Topics: Biomedical Research; Cardiovascular Agents; Chemoprevention; Coronary Restenosis; Genetic Therapy; Humans; Nanoparticles; Stents

PubMed: 24465275
DOI: 10.7150/thno.7210

Review

Authors: M Gottsauner-Wolf, D J Moliterno, A M Lincoff...

The main procedural drawback to percutaneous coronary angioplasty is restenosis of the treated site within 6 months. Despite advances in equipment, technique, and adjunctive therapies, restenosis has occurred in approximately one-third to one-half of all patients. The biology of restenosis can be divided into plaque persistence and recoil, thrombus formation and transformation, and cellular proliferation and vascular remodeling. Animal models of restenosis have helped to elucidate these mechanisms of restenosis and provide a means to test pharmacologic and mechanical strategies to reduce stenosis recurrence. While numerous agents have been tested in animal models, until recently none has translated into benefit in large-scale clinical trials. Two therapeutic "hopefuls" which have recently emerged in clinical practice are the potent platelet inhibitors, glycoprotein IIb/IIIa receptor antagonists, and intracoronary metallic stents. The IIb/IIIa receptor antagonists target thrombus formation at the angioplasty site, thereby minimizing abrupt vessel closure acutely and neointimal growth chronically, while intracoronary stents safely produce a large coronary arterial lumen acutely and prevent vessel recoil. Separately, these therapeutic strategies have been shown to reduce clinical restenosis 20-30% at 6-month follow-up. With these encouraging results, the future will certainly provide more pharmacologic and mechanical therapies targeting restenosis. With increased understanding of the restenotic process and continued refinement of effective treatments, it may be possible one day to prevent stenosis recurrence.

Topics: Angioplasty, Balloon, Coronary; Animals; Coronary Artery Bypass; Coronary Disease; Disease Models, Animal; Humans; Myocardial Revascularization; Stents; Thrombolytic Therapy

PubMed: 8723592
DOI: 10.1002/clc.4960190505

Review

Authors: Gianmarco de Donato, Francesco Setacci, Mariagnese Mele...

Restenosis is one of the main complications in patients undergoing coronary or peripheral revascularization procedures and is the leading cause for their long-term failures. Cilostazol is the only pharmacotherapy that showed an adequate efficacy for preventing restenosis in randomized, controlled studies after coronary or peripheral revascularization procedures. The present review sums up the main clinical evidence supporting the use of cilostazol after revascularization interventions, focusing on all its benefits, warnings, and administration schedules.

Topics: Cardiovascular Agents; Cilostazol; Coronary Artery Disease; Coronary Restenosis; Endovascular Procedures; Humans; Peripheral Arterial Disease; Recurrence; Risk Factors; Tetrazoles; Treatment Outcome

PubMed: 28242395
DOI: 10.1016/j.avsg.2016.08.050

Authors: P J Commerford

Topics: Anticoagulants; Coronary Restenosis; Humans; Hypertension, Pulmonary; Medication Adherence; Percutaneous Coronary Intervention; Warfarin

PubMed: 29297542
DOI: No ID Found

Review

Authors: Li-Jing Chen, Seh Hong Lim, Yi-Ting Yeh...

Atherosclerosis is commonly appreciated to represent a chronic inflammatory response of the vascular wall, and its complications cause high mortality in patients. Angioplasty with stent replacement is commonly performed in patients with atherosclerotic disease. However, the restenosis usually has a high incidence rate in angioplasty patients. Although the pathophysiological mechanisms underlying atherosclerosis and restenosis have been well established, new signaling molecules that control the progress of these pathologies have continuously been discovered. MicroRNAs (miRs) have recently emerged as a novel class of gene regulators that work via transcriptional degradation and translational inhibition or activation. Over 30% of genes in the cell can be directly regulated by miRs. Thus, miRs are recognized as crucial regulators in normal development, physiology and pathogenesis. Alterations of miR expression profiles have been revealed in diverse vascular diseases. A variety of functions of vascular cells, such as cell differentiation, contraction, migration, proliferation and inflammation that are involved in angiogenesis, neointimal formation and lipid metabolism underlying various vascular diseases, have been found to be regulated by miRs. This review summarizes current research progress and knowledge on the roles of miRs in regulating vascular cell function in atherosclerosis and restenosis. These discoveries are expected to present opportunities for clinical diagnostic and therapeutic approaches in vascular diseases resulting from atherosclerosis and restenosis.

Topics: Atherosclerosis; Cell Differentiation; Coronary Restenosis; Gene Expression Regulation; Humans; Inflammation; MicroRNAs; Neovascularization, Pathologic

PubMed: 22931291
DOI: 10.1186/1423-0127-19-79

Meta-Analysis Review

Authors: R Kumar, A Batchelder, A Saratzis...

OBJECTIVE

Do asymptomatic restenoses > 70% after carotid endarterectomy (CEA) and carotid stenting (CAS) increase the risk of late ipsilateral stroke?

METHODS

Systematic review identified 11 randomised controlled trials (RCTs) reporting rates of restenosis > 70% (and/or occlusion) in patients who had undergone CEA/CAS for the treatment of primary atherosclerotic disease, and nine RCTs reported late ipsilateral stroke rates. Proportional meta-analyses and odds ratios (OR) at end of follow-up were performed.

RESULTS

The weighted incidence of restenosis > 70% was 5.8% after "any" CEA, median 47 months (11 RCTs; 4249 patients); 4.1% after patched CEA, median 32 months (5 RCTs; 1078 patients), and 10% after CAS, median 62 months (5 RCTs; 2716 patients). In four RCTs (1964 patients), one of 125 (0.8%) with restenosis > 70% (or occlusion) after CAS suffered late ipsilateral stroke over a median 50 months, compared with 37 of 1839 (2.0%) in CAS patients with no significant restenosis (OR 0.87; 95% CI 0.24-3.21; p = .8339). In seven RCTs (2810 patients), 13 out of 141 (9.2%) with restenosis > 70% (or occlusion) after CEA suffered late ipsilateral stroke over a median 37 months, compared with 33 out of 2669 (1.2%) in patients with no significant restenoses (OR 9.02; 95% CI 4.70-17.28; p < .0001). Following data correction to exclude patients whose surveillance scan showed no evidence of restenosis > 70% before stroke onset, the prevalence of stroke ipsilateral to an untreated asymptomatic > 70% restenosis was seven out of 135 (5.2%) versus 40 out of 2704 (1.5%) in CEA patients with no significant restenosis (OR 4.77; 95% CI 2.29-9.92).

CONCLUSIONS

CAS patients with untreated asymptomatic > 70% restenosis had an extremely low rate of late ipsilateral stroke (0.8% over 50 months). CEA patients with untreated, asymptomatic > 70% restenosis had a significantly higher risk of late ipsilateral stroke (compared with patients with no restenosis), but this was only 5% at 37 months. Overall, 97% of all late ipsilateral strokes after CAS and 85% after CEA occurred in patients without evidence of significant restenosis or occlusion.

Topics: Asymptomatic Diseases; Carotid Stenosis; Endarterectomy, Carotid; Endovascular Procedures; Humans; Incidence; Odds Ratio; Recurrence; Risk Assessment; Risk Factors; Severity of Illness Index; Stents; Stroke; Time Factors; Treatment Outcome

PubMed: 28363431
DOI: 10.1016/j.ejvs.2017.02.016

Authors: Naohiro Funayama, Keigo Kayanuma, Daisuke Sunaga...

BACKGROUND

Drug-coated balloon (DCB) angioplasty has emerged as an effective treatment option for coronary artery lesions; however, the chronic-phase angiographic patterns after DCB angioplasty for lesions have not yet been described.

AIMS

The aim of the present study was to evaluate chronic-phase angiographic classification after DCB angioplasty.

METHODS

This was a single-centre, retrospective, observational study. From June 2016 to August 2022, 708 lesions (670 patients) underwent DCB angioplasty for coronary lesions. Successful DCB angioplasty was defined as a non-flow-limiting dissection, with residual stenosis ≤30% and absence of a bailout stent. A total of 337 lesions (318 patients) were enrolled in this study.

RESULTS

Of the 337 lesions analysed, 91.1% (n=307) were in the non-restenosis group, and 8.9% (n=30) were in the restenosis group. The non-restenosis group was classified into non-restenosis (45.1%; n=152) and lumen enlargement (46.0%; n=155). The restenosis group was classified into focal restenosis (5.0%; n=17), diffuse restenosis (3.6%; n=12), and occlusive restenosis (0.3%; n=1). There were no aneurysms, and plaque cavities were often observed (8.0%). During the chronic phase, residual dissection was seen in only one case (0.3%).

CONCLUSIONS

This report demonstrates for the first time the angiographic classification after DCB angioplasty for coronary lesions. Restenosis patterns were seen in 8.9% of lesions, and half of the restenosis patterns presented a focal restenosis pattern. Late lumen enlargement was observed in 46% of the treated lesions.

PubMed: 39070971
DOI: 10.4244/AIJ-D-23-00064