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(Circulation. 2002;105:2465.)
© 2002 American Heart Association, Inc.

Brief Rapid Communications

Late Vascular Response to Repeat Stenting for In-Stent Restenosis With and Without Radiation

An Intravascular Ultrasound Volumetric Analysis

Yoshihiro Morino, MD; Thosaphol Limpijankit, MD; Yasuhiro Honda, MD; Alexandra J. Lansky, MD; Ron Waksman, MD; Heidi N. Bonneau, RN, MS; Paul G. Yock, MD; Gary S. Mintz, MD; Peter J. Fitzgerald, MD, PhD

From the Center for Research in Cardiovascular Interventions, Stanford University Medical Center, Stanford, Calif (Y.M., T.L., Y.H., P.G.Y., P.J.F.); Washington Hospital Center, Washington, DC (R.W.); Cardiovascular Research Foundation, New York, NY (A.J.L., G.S.M.); and Highlands Consulting Inc, San Jose, Calif (H.N.B.).

Correspondence to Peter J. Fitzgerald, MD, PhD, Center for Research in Cardiovascular Interventions, Stanford University Medical Center, 300 Pasteur Dr, H3554, Stanford, CA 94305-5637. E-mail ivus{at}crci.stanford.edu

Background— Re-stenting of in-stent restenosis (ISR) improves acute angiographic results.

Methods and Results— Volumetric intravascular ultrasound analysis was performed in 70 ISR lesions that received either placebo (n=36) or ¹⁹²Ir radiation (n=34). ISR lesions treated by re-stenting were divided into 3 groups: old stent not re-stented (A), old/new stent overlap (B), and new stent only (C). ISR lesions treated without re-stenting were categorized as D. In placebo patients, postintervention lumen volume index (LVI) was significantly greater in re-stented segments B and C than in non–re-stented segment A (P<0.05).At follow-up, however, LVI was similar in all 4 segments secondary to the increased intimal hyperplasia (IH) reaccumulation within the re-stented segments. In patients treated with ¹⁹²Ir radiation, LVI was maintained from baseline to follow-up only in non–re-stented segments A and D. Conversely, there was a significant decrease in LVI in re-stented segments B and C (P<0.05). Qualitatively, 79% of patients in the irradiated group had stent struts with undetectable neointimal versus only 27% in the placebo group (P<0.001). Coefficient of variation of IH reaccumulation was greater in re-stented segments of ¹⁹²Ir patients (B=57.3% and C=58.9%) than in re-stented segments in placebo patients (B=27.3% and C 26.8%) and non–re-stented segments in irradiated patients.

Conclusions— Additional lumen gain from re-stenting ISR lesions is counteracted by exaggerated neointimal proliferation in placebo patients. Maximum effectiveness and safety of radiation can be achieved for ISR lesions when treated without re-stenting. Thus, regardless of supplementary intravascular brachytherapy, repeat stenting strategies provided little long-term advantage.

Key Words: restenosis • radioisotopes • stents • coronary disease