(Circulation. 1999;100:1872-1878.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Angiographic Patterns of In-Stent Restenosis
Classification and Implications for Long-Term Outcome
From the Angiographic Core Laboratory and Intravascular Ultrasound Imaging and Cardiac Catheterization Laboratories, Washington Hospital Center, Washington, DC.
Correspondence to Roxana Mehran, MD, Cardiovascular Research Foundation, Washington Hospital Center, 110 Irving St NW, Suite 4B-1, Washington, DC 20010.
Background—The angiographic presentation of in-stent restenosis (ISR) may convey prognostic information on subsequent target vessel revascularizations (TLR).
Methods and Results—We developed an angiographic classification
of ISR according to the geographic distribution of intimal hyperplasia
in reference to the implanted stent. Pattern I includes focal
(
10 mm in length) lesions, pattern II is ISR>10 mm within
the stent, pattern III includes ISR>10 mm extending outside the
stent, and pattern IV is totally occluded ISR. We classified a total of
288 ISR lesions in 245 patients and verified the angiographic accuracy
of the classification by intravascular ultrasound. Pattern I was found
in 42% of patients, pattern II in 21%, pattern III in 30%, and
pattern IV in 7%. Previously recurrent ISR was more frequent with
increasing grades of classification (9%, 20%, 34%, and 50% for
classes I to IV, respectively; P=0.0001), as was
diabetes (28%, 32%, 39%, and 48% in classes I to IV, respectively;
P<0.01). Angioplasty and stenting were used
predominantly in classes I and II, whereas classes III and IV were
treated with atheroablation. Final diameter stenosis ranged
between 21% and 28% (P=NS among ISR patterns). TLR
increased with increasing ISR class; it was 19%, 35%, 50%, and 83%
in classes I to IV, respectively (P<0.001).
Multivariate analysis showed that diabetes
(odds ratio, 2.8), previously recurrent ISR (odds ratio, 2.7), and ISR
class (odds ratio, 1.7) were independent predictors of TLR.
Conclusions—The introduced angiographic classification is prognostically important, and it may be used for appropriate and early patient triage for clinical and investigational purposes.
Key Words: restenosis • angioplasty • stents • angiography
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C. Hong, G. S. Chrysant, P. K. Woodard, and K. T. Bae Coronary Artery Stent Patency Assessed with In-Stent Contrast Enhancement Measured at Multi-Detector Row CT Angiography: Initial Experience Radiology, October 1, 2004; 233(1): 286 - 291. [Abstract] [Full Text] [PDF]
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J. Hausleiter, A. Kastrati, J. Mehilli, M. Vogeser, D. Zohlnhofer, H. Schuhlen, C. Goos, J. Pache, F. Dotzer, G. Pogatsa-Murray, et al. Randomized, Double-Blind, Placebo-Controlled Trial of Oral Sirolimus for Restenosis Prevention in Patients With In-Stent Restenosis: The Oral Sirolimus to Inhibit Recurrent In-stent Stenosis (OSIRIS) Trial Circulation, August 17, 2004; 110(7): 790 - 795. [Abstract] [Full Text] [PDF]
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P. W Radke, S. Kobella, A. Kaiser, A. Franke, D. Schubert, E. Grube, P. Hanrath, and R. Hoffmann Treatment of in-stent restenosis using a paclitaxel-eluting stent: acute results and long-term follow-up of a matched-pair comparison with intracoronary {beta}-radiation therapy Eur. Heart J., June 1, 2004; 25(11): 920 - 925. [Abstract] [Full Text] [PDF]
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R. Albiero, S. Silber, C. Di Mario, C. Cernigliaro, S. Battaglia, B. Reimers, A. Frasheri, V. Klauss, J. M. Auge, P. Rubartelli, et al. Cutting balloon versus conventional balloon angioplasty for the treatment of in-stent restenosis: Results of the restenosis cutting balloon evaluation trial (RESCUT) J. Am. Coll. Cardiol., March 17, 2004; 43(6): 943 - 949. [Abstract] [Full Text] [PDF]
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K. Fujii, G. S. Mintz, Y. Kobayashi, S. G. Carlier, H. Takebayashi, T. Yasuda, I. Moussa, G. Dangas, R. Mehran, A. J. Lansky, et al. Contribution of Stent Underexpansion to Recurrence After Sirolimus-Eluting Stent Implantation for In-Stent Restenosis Circulation, March 9, 2004; 109(9): 1085 - 1088. [Abstract] [Full Text] [PDF]
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D. R. Holmes Jr, B. G. Firth, and D. L. Wood Paradigm shifts in cardiovascular medicine J. Am. Coll. Cardiol., February 18, 2004; 43(4): 507 - 512. [Abstract] [Full Text] [PDF]
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D. Greenberg, A. Bakhai, and D. J. Cohen Can we afford to eliminate restenosis?: Can we afford not to? J. Am. Coll. Cardiol., February 18, 2004; 43(4): 513 - 518. [Abstract] [Full Text] [PDF]
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Y. S. Do, E. Y. Kao, F. Ganaha, H. Minamiguchi, K. Sugimoto, J. Lee, C. J. Elkins, P. G. Amabile, M. D. Kuo, D. S. Wang, et al. In-Stent Restenosis Limitation with Stent-based Controlled-Release Nitric Oxide: Initial Results in Rabbits Radiology, February 1, 2004; 230(2): 377 - 382. [Abstract] [Full Text] [PDF]
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G. W. Stone, S. G. Ellis, D. A. Cox, J. Hermiller, C. O'Shaughnessy, J. T. Mann, M. Turco, R. Caputo, P. Bergin, J. Greenberg, et al. A Polymer-Based, Paclitaxel-Eluting Stent in Patients with Coronary Artery Disease N. Engl. J. Med., January 15, 2004; 350(3): 221 - 231. [Abstract] [Full Text] [PDF]
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M. Degertekin, P. A. Lemos, C. H. Lee, K. Tanabe, J.E. Sousa, A. Abizaid, E. Regar, G. Sianos, W. J. van der Giessen, P. J. de Feyter, et al. Intravascular ultrasound evaluation after sirolimus eluting stent implantation for de novo and in-stent restenosis lesions Eur. Heart J., January 1, 2004; 25(1): 32 - 38. [Abstract] [Full Text] [PDF]
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M. Sahara, H. Kirigaya, Y. Oikawa, J. Yajima, K. Ogasawara, H. Satoh, K. Nagashima, H. Hara, Y. Nakatsu, and T. Aizawa Arterial remodeling patterns before intervention predict diffuse in-stent restenosis: An intravascular ultrasound study J. Am. Coll. Cardiol., November 19, 2003; 42(10): 1731 - 1738. [Abstract] [Full Text] [PDF]
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J. W. Moses, M. B. Leon, J. J. Popma, P. J. Fitzgerald, D. R. Holmes, C. O'Shaughnessy, R. P. Caputo, D. J. Kereiakes, D. O. Williams, P. S. Teirstein, et al. Sirolimus-Eluting Stents versus Standard Stents in Patients with Stenosis in a Native Coronary Artery N. Engl. J. Med., October 2, 2003; 349(14): 1315 - 1323. [Abstract] [Full Text] [PDF]
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F. Alfonso, J. Zueco, A. Cequier, R. Mantilla, A. Bethencourt, J. R. Lopez-Minguez, J. Angel, J. M. Auge, M. Gomez-Recio, C. Moris, et al. A randomized comparison ofrepeat stenting with balloon angioplasty in patients with in-stent restenosis J. Am. Coll. Cardiol., September 3, 2003; 42(5): 796 - 805. [Abstract] [Full Text] [PDF]
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P. A. Lemos, F. Saia, J. M.R. Ligthart, C. A. Arampatzis, G. Sianos, K. Tanabe, A. Hoye, M. Degertekin, J. Daemen, E. McFadden, et al. Coronary Restenosis After Sirolimus-Eluting Stent Implantation: Morphological Description and Mechanistic Analysis From a Consecutive Series of Cases Circulation, July 22, 2003; 108(3): 257 - 260. [Abstract] [Full Text] [PDF]
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C. O. Costantini, A. J. Lansky, G. S. Mintz, K. Shirai, G. Dangas, R. Mehran, M. Fahy, S. Slack, M. Coral, P. S. Teirstein, et al. Intravascular brachytherapy for native coronary ostial in-stent restenotic lesions J. Am. Coll. Cardiol., May 21, 2003; 41(10): 1725 - 1731. [Abstract] [Full Text] [PDF]
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A. Colombo, D. Orlic, G. Stankovic, N. Corvaja, V. Spanos, M. Montorfano, F. Liistro, M. Carlino, F. Airoldi, A. Chieffo, et al. Preliminary Observations Regarding Angiographic Pattern of Restenosis After Rapamycin-Eluting Stent Implantation Circulation, May 6, 2003; 107(17): 2178 - 2180. [Abstract] [Full Text] [PDF]
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R. Waksman, E. Cheneau, A. E. Ajani, R. L. White, E. Pinnow, R. Torguson, R. Deible, L. F. Satler, A. D. Pichard, K. M. Kent, et al. Intracoronary Radiation Therapy Improves the Clinical and Angiographic Outcomes of Diffuse In-Stent Restenotic Lesions: Results of the Washington Radiation for In-Stent Restenosis Trial for Long Lesions (Long WRIST) Studies Circulation, April 8, 2003; 107(13): 1744 - 1749. [Abstract] [Full Text] [PDF]
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R Seabra-Gomes In-stent restenosis: intracoronary {beta}-radiation at the crossroads Eur. Heart J., April 1, 2003; 24(7): 583 - 585. [Full Text] [PDF]
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P. Urban, P. Serruys, D. Baumgart, A. Colombo, S. Silber, E. Eeckhout, A. Gershlick, K. Wegscheider, L. Verhees, R. Bonan, et al. A multicentre European registry of intraluminal coronary beta brachytherapy Eur. Heart J., April 1, 2003; 24(7): 604 - 612. [Abstract] [Full Text] [PDF]
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D. T. Ashby, G. Dangas, E. A. Aymong, I. Iakovou, F. Kuepper, R. Mehran, G. W. Stone, M. B. Leon, and J. W. Moses Effect of percutaneous coronary interventions for in-stent restenosis in degenerated saphenous vein grafts without distal embolic protection J. Am. Coll. Cardiol., March 5, 2003; 41(5): 749 - 752. [Abstract] [Full Text] [PDF]
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N Mercado and P.W Serruys A meta-analytical approach for the treatment of in-stent restenosis Eur. Heart J., February 1, 2003; 24(3): 217 - 218. [Full Text] [PDF]
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A. C. Ferreira, A. A. Peter, T. A. Salerno, H. Bolooki, and E. de Marchena Clinical impact of drug-eluting stents in changing referral practices for coronary surgical revascularization in a tertiary care center Ann. Thorac. Surg., February 1, 2003; 75(2): 485 - 489. [Abstract] [Full Text] [PDF]
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