In-stent restenosis

Summary

Despite the enormous progress made in reducing the incidence of restenosis with first and newer-generation drug-eluting stents (DES), the incidence of in-stent restenosis (ISR) requiring target vessel revascularisation (TVR), so-called “DES failure”, is approximately 5-10%, with one estimate suggesting approximately 200,000 repeat revascularisations performed in the US alone. Emerging evidence is now challenging the traditionally held view that ISR is a benign phenomenon with between 30-60% of cases presenting with acute coronary syndrome. The underlying mechanisms of DES restenosis are complex and can be broadly divided into 4 main causes, namely biological, arterial, stent and implantation factors. Evolving concepts concerning mechanisms relating to late restenosis and neoatherosclerosis are also discussed. The treatment of ISR and the determinant factors involved in the development of late stent thrombosis are well described elsewhere and are outside the scope of this review. In this review the numerous causes of DES restenosis are delineated to help identify the potentially controllable and non-controllable factors from the perspective of the interventional cardiologist intending to implant a DES.

Introduction

In the last decade, tremendous progress has been made in reducing the incidence of restenosis with the advent of the drug-eluting stent (DES). With “plain old balloon angioplasty”...