Coronary Artery Disease
Mechanical debulking versus balloon angioplasty for the treatment of diffuse in-stent restenosis

https://doi.org/10.1016/S0002-9149(98)00311-7Get rights and content

Abstract

Previous studies have shown a high rate of repeat intervention after treating diffuse in-stent restenosis with percutaneous transluminal coronary angioplasty (PTCA) alone. It is not clear whether debulking with atherectomy is more effective in this condition. Between January 1994 and February 1997, we treated 60 consecutive patients with diffuse in-stent restenosis of a native coronary artery using conventional PTCA (n = 30) or debulking (with rotational or directional atherectomy) plus adjunctive PTCA (n = 30). Paired angiograms were analyzed by quantitative angiography, and clinical follow-up was obtained in all patients at 1 month, 6 months, and 1 year after revascularization. The mean lesion lengths were 13.5 ± 8.3 and 18.4 ± 13.2 mm in the debulking and PTCA groups, respectively (p = 0.09). Acute procedural success was 100% in both cohorts, with no major complications in either group. Treatment with atherectomy plus adjunctive PTCA resulted in lower postprocedure stenoses (18 ± 10 vs 26 ± 13%, p = 0.01) than treatment with balloon angioplasty alone. At 1-year follow-up, repeat target vessel revascularization was required in 28% of patients in the debulking group compared with 46% in the PTCA group (p = 0.18). Independent predictors of the need for repeat target vessel revascularization were longer lesion lengths, diabetes mellitus, and smaller postprocedure lumen diameter. Thus, the strategy of atherectomy and adjunctive PTCA for diffuse in-stent restenosis is safe, improves acute angiographic results compared with PTCA alone, and may decrease the need for target vessel revascularization.

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Study population

Between January 1, 1994, and January 31, 1997, 125 patients underwent percutaneous coronary revascularization for initial management of symptomatic in-stent restenosis at Beth Israel-Deaconess Medical Center. Of these, 34 patients (27%) were treated for focal restenotic lesions (confined predominantly to the stent articulation site or to one of the ends of the stent), and 31 patients (25%) were treated for restenosis in a saphenous vein graft stent. These patients were excluded from this study.

Patient characteristics

Baseline demographic and clinical characteristics of the study population are described in Table I. The treatment groups were generally well matched with respect to age, gender, extent of coronary disease, and type of stent. The median time to restenosis was similar between the debulking and PTCA groups (153 vs 115 days, respectively, p = 0.20). Patients in the debulking group were somewhat more likely to have diabetes mellitus (43% vs 23%, p = 0.10) but had otherwise similar coronary disease

Discussion

With the exponential growth in coronary stent implantation, treatment of in-stent restenosis has become an increasingly frequent challenge. Although many cases of in-stent restenosis can be treated successfully with simple redilation,5, 7 previous studies have shown that patients with a diffuse pattern of in-stent restenosis are at increased risk for recurrent restenosis.8, 9 In this study, we compared the results of treatment for diffuse in-stent restenosis using 2 alternative

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Dr. Cohen was supported in part by a Clinician-Scientist Award from the American Heart Association, Dallas, Texas.

Author deceased on March 5, 1998.

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