Nearly 10% of PCIs performed for in-stent restenosis
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PCIs performed on in-stent restenosis lesions are often treated with another stent, researchers found.
The study, published in the Journal of the American College of Cardiology, also found that patients who underwent PCI for in-stent restenosis lesions were less likely to have non-STEMI or STEMI compared with those without in-stent restenosis, but both groups had similar rates of in-hospital complications and hospital length of stay.
“Those findings provide practical guidance for clinicians with regard to setting expectations for patients undergoing coronary stent implantation in terms of communicating the potential frequency of needed repeat intervention after initial stenting, emphasizing the importance of compliance with risk factor-modifying therapy and antiplatelet therapy to reduce acute ischemic events after stenting [and] informing the patient with potential [in-stent restenosis], at the time of presentation, that the most likely treatment they will receive in the U.S. is another stent,” Issam D. Moussa, MD, MBA, medical director of the Heart and Vascular Institute at Carle Health, and professor and head of the department of clinical sciences at Carle Illinois College of Medicine at University of Illinois at Urbana-Champaign, told Healio.
Data from CathPCI registry
In this retrospective analysis, researchers analyzed data from 5,100,394 patients (mean age, 65 years; 68% men) from the CathPCI registry of the National Cardiovascular Data Registry who underwent PCI from 2009 to 2017. Patients with cardiogenic shock or cardiac arrest, or who underwent salvage PCI were excluded from this analysis.
The primary exposure variable was a patient with any lesion considered an in-stent restenosis lesion despite additional lesions during the procedure. The first PCI was considered the index procedure for patients who underwent more than one PCI.
Of the patients in the study, 10.6% underwent PCI for in-stent restenosis.
“Although one may interpret the steady rate of repeat PCI for [in-stent restenosis] as lack of progress, it’s important to keep in mind that over the period of this study, more complex patients have been receiving coronary stents,” Moussa said in an interview. “Therefore, a steady rate of need for repeat intervention may indicate increased efficacy of stents over time due to progress in technology and implantation technique. Of course, this is a hypothesis and not an observation from this study.”
For patients who underwent in-stent restenosis PCI, the rate of patients with bare-metal stent in-stent restenosis declined from the third quarter of 2009 to the second quarter of 2017 (2.6% to 0.9%; P < .001), whereas the proportion of patients with drug-eluting stent in-stent restenosis increased during this period (5.4% to 6.3%; P < .001).
Compared with patients without in-stent restenosis PCI, those who underwent the procedure for in-stent restenosis lesions were less likely to present with non-STEMI (18.7% vs. 22.5%; P < .001) or STEMI (8.5% vs. 15.7%; P < .001).
In-hospital complications and hospital length of stay did not significantly differ between both groups in the propensity-matched population.
“Although reducing stent strut thickness has contributed to improved outcomes after stenting, it’s likely that we’ve reached the limits of this approach,” Moussa told Healio. “Research should focus on two areas: further development of second-generation biodegradable stent technology that enables manufacturing of stents with thinner struts without compromising mechanical properties, and performing definitive large randomized clinical trials to evaluate the efficacy of drug-eluting balloons for treatment of in-stent restenosis.”
Potential increase in the future
In a related editorial, Adnan Kastrati, MD, professor of cardiology and head of catheterization laboratory at Deutsches Herzzentrum Muenchen in Munich, and Salvatore Cassese, MD, PhD, interventional cardiologist at Deutsches Herzzentrum Muenchen, wrote: “Despite contemporary DES platforms having substantially improved in terms of both safety and efficacy, [in-stent restenosis] occurs in a considerable proportion of patients. The widespread adoption of DES therapy worldwide and the increasing CAD complexity treated in daily practice suggest that the disease burden associated with [in-stent restenosis] is expected to increase in the years to come.”
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For more information:
Issam D. Moussa, MD, MBA, can be reached at imoussa@illinois.edu.
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