Coronary Artery Disease
Clinical and angiographic predictors of recurrent restenosis after percutaneous transluminal rotational atherectomy for treatment of diffuse in-stent restenosis

https://doi.org/10.1016/S0002-9149(98)01074-1Get rights and content

Abstract

Due to the widespread use of stents in complex coronary lesions, stent restenosis represents an increasing problem, for which optimal treatment is under debate. “Debulking” of in-stent neointimal tissue using percutaneous transluminal rotational atherectomy (PTRA) offers an alternative approach to tissue compression and extrusion achieved by balloon angioplasty. One hundred patients (70 men, aged 58 ± 11 years) with a first in-stent restenosis underwent PTRA using an incremental burr size approach followed by adjunctive angioplasty. The average lesion length by quantitative angiography was 21 ± 8 mm (range 5 to 68) including 22 patients with a length ≥40 mm. Twenty-nine patients had complete stent occlusions with a lesion length of 44 ± 23 mm. Baseline diameter stenosis measured 78 ± 17%, was reduced to 32 ± 9% after PTRA, and further reduced to 21 ± 10% after adjunctive angioplasty. Primary PTRA was successful in 97 of 100 patients. Clinical success was 97%, whereas 2 patients developed non–Q-wave infarctions without clinical sequelae. Clinical follow-up was available for all patients at 5 ± 4 months without any cardiac event. Angiography in 72 patients revealed restenosis in 49%, with necessary target lesion reintervention in 35%. The incidence of rerestenosis correlated with the length of the primarily stented segment and the length of a first in-stent restenosis. Thus, PTRA offers an alternative approach to treat diffuse in-stent restenosis. Neointimal debulking of stenosed stents can be achieved effectively and safely. PTRA resulted in an acceptable recurrent restenosis rate in short and modestly diffuse lesion, whereas the restenosis rate in very long lesions remains high despite debulking.

Section snippets

Patient selection

Patients with a first in-stent restenosis in native coronary arteries fulfilling the following criteria were prospectively and consecutively recruited: inclusion criteria: angina pectoris and/or myocardial ischemia related to the target lesion, diameter stenosis >50% within or 5 mm proximal or distal to the stent edges, and stents implanted ≥3 months before this intervention; exclusion criteria: stents deployed at or directly distal to a bend of >45°, coil stents, recurrent in-stent restenosis,

Patient characteristics and stent implantation

One hundred consecutive patients (70 men, aged 58 ± 11 years) were studied. Demographic, clinical, and angiographic characteristics are outlined in Table I. In 57 patients, the initial stent implantation was the first percutaneous intervention, and 34 patients including 20 patients with stenting for restenosis had ≥1 previous nonsurgical coronary intervention.

The indication for stent implantation was a de novo lesion in 80% including chronic occlusions in 28% and a restenosed artery in 20%.

Discussion

The results, although preliminary with regard to long-term follow-up, indicate that PTRA is a feasible and safe approach for treating symptomatic diffuse in-stent restenosis and achieves excellent acute results; there is clear tissue debulking within the restenosed lesion using PTRA; and the angiographic long-term outcome demonstrates good results in short or medium length (≤20 mm) lesions, whereas long and very diffuse lesions revealed a less favorable outcome.

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      These findings have raised the hope that the recurrence rate could be lowered by ablation of the neointima. Initial investigations utilizing rotational ablation proved efficacy in neointimal removal by this method, and in long-term results the restenosis rate of diffuse ISR tended to be lower than after PTCA.18,19 In contrast to these preliminary findings, results of this larger randomized investigation documented a higher restenosis rate after PTCR than after PTCA of diffuse ISR in general.

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