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Optimal treatment for peripheral in-stent restenosis depends on lesion size

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HOLLYWOOD, Fla. — The optimal treatment for in-stent restenosis in the peripheral arteries depends on lesion size. For short lesions, drug-coated balloons and drug-eluting stents appear to yield the best outcomes, while drug-eluting stents and endoprostheses appear to be the best solutions for long lesions, according to a speaker at the International Symposium on Endovascular Therapy.

Johannes Lammer, MD, from Medical University of Vienna, Austria, said there are three main patterns of stent failure: acute stent trauma due to intimal hyperplasia from stent placement; chronic stent trauma due to intimal hyperplasia from wall shear stress and chronic outward force; and edge stenosis due to compliance mismatch.

Johannes Lammer

“Oversizing the stent tends to cause in-stent restenosis,” he said during a presentation.

While 1-year results of DEBATE-ISR suggested that DCBs were better than regular balloon angioplasty at treating in-stent restenosis in the peripheral arteries, at 3 years there was no longer a significant difference in target lesion revascularization between the therapies (P = .8), he said.

In the new PACUBA study, DCBs yielded better patency at 1 year than plain angioplasty in patients needing treatment for in-stent restenosis, but rates were low across the board (40.7% vs. 13.4%; P = .016), he said.

In a single-arm study investigating paclitaxel-eluting stents as a treatment for peripheral in-stent restenosis, the 1-year patency rate was 78.8%, the 1-year target lesion revascularization rate was 81% and the 2-year TLR rate was 60.8%, according to Lammer.

In the RELINE trial, compared with conventional balloon angioplasty, an endoprosthesis (Viabahn, W.L. Gore) was associated with better patency at 1 year (74.8% vs. 24%; P < .001) and more freedom from TLR at 1 year (80% vs. 42%; P < .001), he said.

Lammer noted that excimer laser atherectomy appears to be a better strategy for in-stent restenosis in peripheral arteries than regular balloon angioplasty. However, 1-year results of the EXCITE-ISR trial indicated that neither atherectomy nor regular balloon angioplasty yielded a high rate of freedom from TLR, he said.

“In short lesions, TASC A and B, DES and DCB may be the first choice,” Lammer concluded. “In long lesions, TASC C and D, endoprosthesis and DES are recommended. Plain balloon angioplasty and atherectomy are non-recommendable options.” – by Erik Swain

Reference:

Lammer J. Session II: Drug Elution, Stents, Balloons/SFA with Focus on Drug-Elution and Trial Data. Presented at: International Symposium on Endovascular Therapy; Feb. 6-10, 2016; Hollywood, Fla.

Disclosure: Lammer reports no relevant financial disclosures.