Restenosis

• Overview
• Predictors
• Treatment
• Prevention

Restenosis Overview      Archive 2000-2001

TCT 2002 Abstracts

• In-Stent Restenosis

PowerPoint presentation
An Assessment of Restenosis on the Eve of Drug-Eluting Stents 
by Dr. James P. Zidar

Predictors     Archive 1985-2001

TCT 2002 Expert Presentations

Role of the Endothelium in Modulating Restenosis, and Comparative Potency of Different Agents on SMC vs Endothelial Proliferation	N. Kipshidze
Impact of Metallic Contaminants on Restenosis	j. palmaz

Postprocedure chest pain (PPCP) after coronary stenting: implications on clinical restenosis
A.S. Kini, P. Lee, C.A. Mitre, M.E. Duffy, S.K. Sharma
J Am Coll Cardiol 2003;41:33-38
Full text via ScienceDirect :
http://www.sciencedirect.com/science?_ob=GatewayURL&_origin=CONTENTS&_method=citation
Search&_piikey=S0735109702026177&_version=1&md5=e82d379c7af02d50e171eef2e3f8d09c
This study suggests micromyonecrosis and vessel stretch as causes of PPCP. Postprocedure chest pain is associated with similar short-term outcome as no PPCP, but has higher restenosis, perhaps mediated by deep vessel wall injury. Therefore, PPCP may identify patients at high risk for restenosis. 

Morphological predictors of restenosis after coronary stenting in humans 
Farb A, et al. 
Circulation 2002;105:2974-80.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12081990
http://www.circulationaha.org/cgi/content/full/105/25/2974http://www.circulationaha.org/cgi/content/abstract/105/25/2974 
Coronary stenting that is accompanied by medial damage or penetration of the stent into a lipid core induces increased arterial inflammation, which is associated with increased neointimal growth. These data suggest the use of stenting strategies that reduce inflammation and neoangiogenesis to reduce the incidence of restenosis.

Predictors of recurrent restenosis after coronary stenting: an analysis of 197 patients 
Kishi K, et al. 
J Invasive Cardiol 2002;14:187-91.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11923572  
The major recurrent in-stent restenosis predictors identified included female gender, final diameter stenosis, and diameter stenosis after predilatation.

What is "the matter" with restenosis in 2002? 
Sousa JE, et al. 
Circulation 2002;105:2932-3.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12081980
http://www.circulationaha.org/cgi/content/full/105/25/2932

The impact of lesion length and reference vessel diameter on angiographic restenosis and target vessel revascularization in treating in-stent restenosis with radiation 
Ajani AE, et al. 
J Am Coll Cardiol 2002;39:1290-6.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11955846 
Intracoronary radiation therapy, compared to placebo, results in a significant reduction of angiographic restenosis across all vessel sizes, with a trend toward reduction of angiographic restenosis across all lesion lengths; this effect is seen predominantly in small vessels and diffuse lesions.

News (italiano) Apr 2002
Il fenotipo dellaptoglobina predice il rischio di restenosi dopo impianto di stent
I polimorfismi allelici del gene dell'aptoglobina oltre ad avere importanza per le malattie vascolari hanno anche un valore predittivo per il rischio di restenosi dopo impianto di stent. Il Dr. Andrew P. Levy e colleghi hanno determinato il fenotipo dell'aptoglobina con metodica elettroforetica. Nei pazienti con uno o due alleli per l'aptoglobina 2, il rischio era 31% e 36%, ...

Full text journal article Sep 2002
Greater Pathogen Burden but Not Elevated C-Reactive Protein Increases the Risk of Clinical Restenosis After Percutaneous Coronary Intervention
Percutaneous coronary intervention (PCI), including balloon angioplasty, intracoronary stent deployment, and a variety of atherectomy procedures, has become an accepted approach to coronary revascularization, with procedural success rates often reaching higher than 95%.

Treatment     Archive 1995-2001

TCT 2002 Expert Presentations

RESCUT and REDUCE II cast doubt on Cutting Balloon's major niche
with slide /The razor-fitted Cutting Balloon^TM is used at many centers to treat in-stent restenosis, but 2 randomized trials have questioned whether it's any better than the standard balloon for that indication. Some experts wonder whether the expensive device makes a big clinical difference, while others see good opportunities for it in selected cases. 

Meeting Coverage
RESCUT: Restenosis Cutting Balloon Evaluation
Cutting balloon angioplasty yields similar rates of in-stent restenosis compared with conventional PTCA; however, the procedure requires fewer devices and is associated with a lower incidence of balloon slippage.

PCR 2002 Meeting Coverage

Repeat stenting offers few advantages for in-stent restenosis
Repeat stenting strategies provide little long-term advantage for in-stent restenosis, regardless of supplementary intravascular brachytherapy, according to a new analysis. (Morino Y et al. Circulation 2002; 105: published online before print, May 13, 2002.) [ May 13, 2002 ]

ACC 2002 Meeting Coverage

Geographic miss blamed for 12.2% MACE in in-stent restenosis patients: TAXUS III
Investigators for the 30-patient TAXUS III trial evaluating the paclitaxel-coated NIRx stent for in-stent restenosis say that the device appears to be safe and easily implanted in this group of patients. They blame the 4 cases of target lesion revascularization within 6-month follow-up on geographic miss. American College of Cardiology 51st Annual Scientific Session. [ Mar 22, 2002 ]

Restenosis after angioplasty
Cannon RO, 3rd. 
N Engl J Med 2002;346:1182-3.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11961145 
http://content.nejm.org/cgi/content/full/346/16/1182 

Cardiology patient page. Restenosis: repeat narrowing of a coronary artery: prevention and treatment 
Dangas G, et al. 
Circulation 2002;105:2586-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12045160 
http://www.circulationaha.org/cgi/content/full/105/22/2586 

First clinical experience with a paclitaxel derivate-eluting polymer stent system implantation for in-stent restenosis: immediate and long- term clinical and angiographic outcome 
Liistro F, et al. 
Circulation 2002;105:1883-6.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11997271 
http://www.circulationaha.org/cgi/content/full/105/16/1883 
http://www.circulationaha.org/cgi/content/abstract/105/16/1883 
This first experience with QuaDS-QP2 stent implantation for in-stent restenosis revealed minimal intimal hyperplasia at the 6-month follow- up. However, the antiproliferative effect was not maintained at the 12- month follow-up, resulting in delayed occurrence of angiographic restenosis.

Rotational atherectomy does not reduce recurrent in-stent restenosis: results of the angioplasty versus rotational atherectomy for treatment of diffuse in-stent restenosis trial (ARTIST) 
vom Dahl J, et al. 
Circulation 2002;105:583-8.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11827923 
http://www.circulationaha.org/cgi/content/full/105/5/583 
http://www.circulationaha.org/cgi/content/abstract/105/5/583 
In terms of the primary objective of the study, PTCA produced a significantly better long-term outcome than ROTA followed by adjunctive low-pressure PTCA.
Summary:

Use of localised intracoronary beta radiation in treatment of in-stent restenosis: the INHIBIT randomised controlled trial 
Waksman R, et al. 
Lancet 2002;359:551-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11867107 
Vascular brachytherapy using pure beta-emitter 32P delivered into a centreing catheter via an automatic afterloader can be used to reduce overall revascularisation in patients undergoing treatment for diffuse in-stent restenosis.

Prevention   Archive 1977-2001

TCT 2002 Meeting Coverage

TCT 2002 Expert Presentations

Oral Rapamycin

Oral Sirolimus to Prevent Restenosis -- A Cheaper Alternative to Drug-Coated Stents?
Two small pilot studies reveal that as an adjunct to standard angioplasty and stenting, oral sirolimus has the potential to reduce the incidence of ISR.

ESC 2002 Meeting Coverage

In-Depth Late-Breaking Clinical Trials II: BEST, PRAGUE-4, Euro-SPAH, OPTIMAAL, ACE
Luis Gruberg, MD

ORBIT: Oral rapamycin may reduce restenosis after stenting
with slide / Rapamycin, one of the agents now generating such excitement in the setting of drug-eluting stents, may also prove to be a useful oral preventive against restenosis in patients receiving bare stents. An open-label study shows oral rapamycin given for 30 days after PCI was well tolerated and was associated with low rates of restenosis and late loss. 
European Society of Cardiology Congress 2002 [ Sep 02, 2002 ]

EuroSPAH: Trial of intravascular sonography fails to meet primary antirestenosis end point but still cuts revascularization
A randomized trial of intravascular sonography for the prevention of restenosis failed to meet its primary end point of a 0.21-mm reduction in late loss but still found a highly significant reduction in revascularization with the therapy compared with sham treatment. A larger study, dubbed SWING, expected to report at the upcoming AHA meeting, should help clarify this finding, researchers say. 
European Society of Cardiology Congress 2002 [ Sep 09, 2002 ]

Folic acid/B vitamin combination reduces TLRs 1 year after PCI
Schnyder G et al. 
JAMA 2002;288:973-9. [ Aug 27, 2002 ]
A 1-year follow-up study to previously published 6-month results indicates that homocysteine-lowering therapy with folic acid and vitamins B12 and B6 reduced the rate of target lesion revascularizations (TLRs) compared with placebo, even 6 months after the therapy was stopped. 

Relation of homocysteine, vitamin B(12), and folate to coronary in- stent restenosis
Genser D, et al.
Am J Cardiol 2002;89:495-9.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11867030
Univariate and multivariate analyses revealed no significant differences between patients with or without restenosis with regard to total homocysteine (median [interquartile range]: 12.9 [11.2 to 14.8] and 12.4 [10.3 to 15.4] micromol/L, respectively), folate (16.1 [12.4 to 20.5] and 15.4 [12.5 to 19.5] nmol/L, respectively), or vitamin B(12) (239.0 [182.5 to 322.1] and 258.4 [205.8 to 330.5] pmol/L, respectively). These results suggest that homocysteine, folate, and vitamin B(12) are not related to the angiographically determined rate of coronary in-stent restenosis after 6 months.

Oral sirolimus-type drugs preferable to coated stents?
The clinical trial results with drug-coated stents have been overblown, and more long-term data are needed before investing the significant sums necessary for routine use of these devices, an expert says. Farb A et al. Circulation 2002: published online before print. [ Oct 01, 2002 ]

Oral Everolimus Inhibits In-stent Neointimal Growth
Farb A, John M, Acampado E, Kolodgie FD, Prescott MF, Virmani R
Circulation. 2002;106(18):2379-2384
http://www.medscape.com/viewarticle/445909_2 

B vitamins and restenosis after coronary angioplasty
Bostom AG, et al.
N Engl J Med 2002;346:1093-5.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11936123

B vitamins and restenosis after coronary angioplasty
Chirieac DV, et al.
N Engl J Med 2002;346:1093-5.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11932482
http://content.nejm.org/cgi/content/full/346/14/1093

Full text journal article Mar 2002
The Impact of Tranilast on Restenosis After Coronary Angioplasty: The Second Tranilast Restenosis Following Angioplasty Trial (TREAT-2)
Oral administration of tranilast for 3 months markedly reduces the restenosis rate of PTCA, even in restenotic lesions.

Cardiology patient page
Restenosis: repeat narrowing of a coronary artery: prevention and treatment
Dangas G, et al.
Circulation 2002;105:2586-7.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12045160
http://www.circulationaha.org/cgi/content/full/105/22/2586

Evidence that angiotensin-converting enzyme inhibitor use diminishes the need for coronary revascularization after stenting
Ellis SG, et al.
Am J Cardiol 2002;89:937-40.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=11950431
ACE inhibitors appear to decrease late revascularization, possibly due to a reduction in restenosis after coronary stenting.

A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization (RAVEL Study)
Morice MC, et al.
N Engl J Med 2002;346:1773-80.
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&dopt=r&uid=12050336
http://content.nejm.org/cgi/content/full/346/23/1773
http://content.nejm.org/cgi/content/abstract/346/23/1773
As compared with a standard coronary stent, a sirolimus- eluting stent shows considerable promise for the prevention of neointimal proliferation, restenosis, and associated clinical events.