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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Focal or diffuse intimal proliferation inside the stent or at the edges, resulting in restenosis

  • Late luminal loss of ≥ 50% compared with acute luminal gain is generally considered in-stent restenosis (ISR)

  • Recurrent angina or detection of ischemia in the vascular territory treated on stress tests Confirmed at angiography

GENERAL CONSIDERATIONS

  • Stimulation of smooth muscle cells followed by proliferation and migration leads to neointimal thickening

  • With plain balloon angioplasty, the ISR rate is 30–50%

  • With bare metal stents, the ISR rate is between 20% and 30%

  • With the advent of chemotherapy-coated stents (paclitaxel or sirolimus coated), the ISR rate is up to 9%, depending on the complexity of the stenoses treated

  • Patient factors that increase the risk of restenosis:

    • – Diabetes mellitus

    • – Smoking

    • – Severe angina before stent placement

  • Anatomic risk factors that increase the risk of ISR:

    • – Chronic total occlusion

    • – Saphenous vein grafts

    • – Long lesions

  • Procedural variables that increase the risk of ISR:

    • – Post stenting minimal lumen diameter < 3.5 mm

    • – Use of first-generation stents (paclitaxel)

    • – Presence of thrombus

  • Peak incidence is between 3 and 6 months

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • May be asymptomatic

  • Angina at rest or on exertion, sometimes worse than before intervention

  • Dyspnea, leg edema may occur secondary to heart failure from ischemia

  • Palpitations and syncope may occur as a consequence of arrhythmias

PHYSICAL EXAM FINDINGS

  • Elevated jugular venous distention if heart failure present

  • S3 and S4

  • Bibasilar lung rales if heart failure present

DIFFERENTIAL DIAGNOSIS

  • Symptoms early after stenting (< 1 month) usually mean in-stent thrombosis

  • Symptoms late after stenting (> 9 months) usually mean progressive disease in nonstented segments

  • Other causes of chest pain or positive stress tests may be found

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC, brain natriuretic peptide, troponin

ELECTROCARDIOGRAPHY

  • ECG may show ischemic changes or myocardial infarction findings

IMAGING STUDIES

  • Stress or vasodilator perfusion nuclear imaging

  • Stress or dobutamine echocardiogram

DIAGNOSTIC PROCEDURES

  • Coronary angiogram

  • Optical coherence tomography to assess minimum luminal diameter or area

  • Intravascular ultrasound imaging can also be used to assess the lesion lumen

TREATMENT

CARDIOLOGY REFERRAL

  • All patients with suspected ISR should be evaluated by a cardiologist

HOSPITALIZATION CRITERIA

  • If the presentation is unstable angina, myocardial infarction, or heart failure, hospitalization is required

  • Following percutaneous coronary intervention (PCI) of ISR

MEDICATIONS

  • Antianginal medications if re-revascularization not feasible

  • Dual antiplatelet therapy

  • A statin

THERAPEUTIC PROCEDURES

  • Chemotherapy-coated balloon angioplasty, ...

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