Rotational Atherectomy for In-Stent Restenosis
Rotational Atherectomy for In-Stent Restenosis
ABSTRACT & COMMENTARY
Synopsis: In symptomatic patients with in-stent restenosis, rotational atherectomy is a safe and feasible technique and has a low "re-restenosis" rate relative to balloon angioplasty.
Source: Sharma SK, et al. J Am Coll Cardiol 1998;32:1358-1365.
New stents with improved stent technology have made it easier to go where no stent has gone before. Unfortunately, both the increasing use of stents, in general, and the ability to stent previously unstenable lesions has led to an increase in the prevalence of in-stent restenosis (ISR). Since ISR is secondary to neointimal proliferation, debulking intimal hyperplasia prior to balloon angioplasty is an appealing approach to this problem. Sharma and associates sought to evaluate the clinical safety and long-term results of rotational atherectomy for the treatment of in-stent restenosis. One hundred consecutive patients with symptomatic first-time ISR underwent rotational atherectomy. All had stents of at least 3.0 mm deployed with high-pressure inflations. Restenosis was defined as a greater than 50% diameter stenosis within or at the edge of a stented lesion that presented at greater than eight weeks after initial stent placement. Early ISR presented within 90 days. Intravascular ultrasound was used to evaluate the mechanism of lumen enlargement in the first 15 cases and in the last 30 cases.
Procedural success (angiographic residual stenosis of less than 30%) was achieved in all patients. The short-term composite end points of death, bypass surgery, or Q-wave infarction during the hospital stay did not occur in any patients. Follow-up was a minimum of nine months post-atherectomy with a mean of 13 ± 5 months. Five patients had an uncomplicated non-Q-wave infarction with re-restenosis. Recurrent ISR occurred in 28/100 patients or 28% of the patients at a mean of 102 ± 52 days. Of these 28, two were treated medically and the other 26 underwent percutaneous (20) or surgical (6) revascularization. Thus, in a patient population already known to be at high risk for re-restenosis, Sharma et al were able to achieve a long-term restenosis rate of 28% with rotational atherectomy, which is lower than historical controls using balloon angioplasty alone.
Comment by Michael H. Crawford, MD
The treatment of ISR has become an increasingly common challenge. The physiology of ISR is neointimal proliferation, not stent recoil. This neointimal proliferation is generally diffuse but may be focal or at the stent edges. The plaque/tissue burden may favor the approach of removing or "debulking" the lesion and then performing balloon angioplasty to further improve the lumen within the stent.
The technique most commonly used for debulking is rotational atherectomy. The debulking may prove superior over simply compressing the plaque with balloon angioplasty. Sharma et al were able to safely and effectively treat 100 patients who returned with ISR. The nine-month follow-up identified only 28% of patients with re-restenosis. This is a remarkably low rate considering the proven propensity of these patients for restenosis.
There has yet to be a large randomized trial comparing treatment strategies for ISR; however, a multicenter registry in Europe—the BARASTER registry—has shown rotational atherectomy plus balloon angioplasty to be far superior to rotational atherectomy alone. Some recently published small series with ISR report re-restenosis rates of 20%. However, this group of patients appeared to have predominantly focal restenosis. Sharma et al’s group of patients had predominantly diffuse restenosis and, thus, had a much greater plaque burden.
Laser and radiation are also promising techniques in the treatment of ISR; however, these are not widely available technologies.
The strategy of using intravascular ultrasound to identify a large plaque burden vs. an underdeployed or undersized stent provides additional insight into the mechanism of restenosis. This information may then direct us to "debulk" using rotational atherectomy with balloon angioplasty vs. balloon angioplasty alone in an undersized, underdeployed stent.
This series of patients treated by Sharma et al provides a ray of hope in an otherwise daunting area. Rotational atherectomy was used safely and effectively in this patient group. Thus, the use of rotational atherectomy may prove an invaluable asset in those patients with ISR.
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