Although coronary artery stents have been important in decreasing restenosis and reducing chronic arterial remodeling, restenosis of stented arteries remains a major problem. Stented arterial segments are prone to neointimal hyperplasia, the primary cause of stent restenosis.
Jolly and associates reviewed the management of in-stent restenosis, evaluating long-term outcomes and specifically comparing the results of rotational atherectomy to repeat balloon dilation. Between January 1993 and December 1996 at one site, 160 patients were treated for in-stent restenosis with percutaneous transluminal coronary angioplasty (PTCA). Of this group, 116 patients underwent PTCA, 30 patients underwent rotational atherectomy and 14 patients had repeat stenting. The choice of the intervention was at the discretion of the attending physician. Procedural success was defined as a final stenosis of less than 50 percent and a total decrease in stenosis of greater than 20 percent with no major in-hospital complications. Complete revascularization was defined as successful percutaneous treatment of all vessels that measured greater than 1.5 mm and with a stenotic lesion of 50 percent or more.
A total of 202 lesions were treated in the 160 patients. Target vessel failure was markedly associated with smoking and native vessel diameter of 3 mm or less. Saphenous vein graft location of the lesion and current smoking were independent risk factors for target vessel failure and target vessel revascularization. No notable difference was noted on clinical follow-up in target vessel revascularization or target vessel failure between patients treated with rotational atherectomy and those treated with balloon angioplasty.
The authors conclude that debulking techniques such as rotational atherectomy, laser coronary angioplasty and directional atherectomy have been believed to be more efficacious than balloon angioplasty and have been increasingly used for in-stent restenosis, but the ability to assess any notable difference is limited by small numbers of rotational atherectomies and clinical events on follow-up. Persistent smoking appears to be the most significant clinical predictor of reintervention or major acute coronary events. Saphenous vein graft location was the major anatomic predictor of target vessel failure and the need for revascularization.