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(Circulation. 2000;101:946.)
© 2000 American Heart Association, Inc.

Editorial

Predicting Restenosis

Bigger Is Better but Not Best

David P. Faxon, MD

From the University of Southern California Keck School of Medicine, Los Angeles, Calif.

Correspondence to David P. Faxon, MD, Professor of Medicine, Chief, Division of Cardiology, University of Southern California Keck School of Medicine, 1355 San Pablo St, Suite 117, Los Angeles, CA 90033. E-mail dfaxon@hsc.usc.edu

Key Words: Editorials • restenosis • angioplasty • prognosis • coronary blood flow

The ability to accurately predict restenosis after angioplasty continues to be elusive, despite two decades of clinical and angiographic studies. Although these studies have shown that a number of clinical, procedural, and angiographic factors are related to recurrence of the stenosis, the overall predictive value of these factors remains low.¹ Angiographic factors have been most extensively studied and variable, such as ostial lesion location, proximal lesion location, left anterior descending artery lesion location, bifurcation lesion, eccentric lesion, and long lesion, and those vessels receiving collaterals have been shown to have a higher rate of restenosis as well. Perhaps one of the most important advances in our understanding of restenosis has been the relationship between the final minimal lumen diameter (MLD), or residual stenosis, and the likelihood of developing restenosis. Often termed "bigger is better," the inverse relationship between final MLD or percent stenosis and restenosis has been widely studied and well validated.² The principal of obtaining the largest possible luminal opening during the procedure is now the primary goal of all angioplasty procedures and is the major explanation for why stents reduce restenosis and why their use has become so popular. Even in very large databases, MLD correctly predicted the occurrence of restenosis in only 30% of patients. The price paid for a bigger lumen, however, is more renarrowing, due to unfavorable remodeling and exaggerated intimal hyperplasia. Fortunately, Mother Nature has been kind and, in the clinical setting, only renarrows the artery to roughly half the initial gain in lumen . . . [Full Text of this Article]

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