(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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