Posted in Cardiology -Interventional -PCI, cardiology- coronary care, Cardiology-Coronary artery disese, tagged in stent restenosis, instent restenosis, isr, poba for instent restenosis, re stenosis in des on October 15, 2011| Leave a Comment »
Instent restenosis is a common problem.
Diffuse long segment instent restenosis is somewhat rare.
We encountered one such patient who had diffuse instent restenosis of RCA.
ISR is ssupposed to be rare in DES, but here ISR occured with a Cypher stent one year following implantation
He presented with angina which was relieved by plain baloon angioplasty.
link to a related article in this site regarding the mangementof ISR.
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, cardiology -Therapeutics, cardiology- coronary care, Cardiology-Land mark studies, tagged bms vs des for instent restenosis, des for irs, instent restenosis, irs, mehrans classification of irs, stent occlusion on August 17, 2011| Leave a Comment »
How do you tackle In-stent restenosis (ISR) ?
Answer: Please note , there is no single response answer for this question .
Instent restenosis (ISR) is commonly seen with BMS .This is primarily because we are busy blaming DES for stent thrombosis and we do not want to give a double blow to DES .There is a significant population roaming with ISR involving DES . BMS is in vogue for nearly 2 decades, hence it is natural to see more of it. In due course , DES is expected to catch up with BMS and would lead in ISR as well .
The issues in PCI for ISR
Though any of the above 6 strategies may be appropriate ,the urge to put another stent within the IRS , prevails over all other options in most centers. This is more off an Interventionist talent show off !
Please remember , the common principles must apply in all patients before an PCI . Simply stated , this principle involves assessing symptoms, residual resting ischemia, myocardium at risk during stress, viable muscle mass etc .Lesion characteristics should come last in the work up. ( A cardiologist should not report a coronary angiogram , if does not not know basic clinical parameters.)
It is good to have a rule that “reserves intervention” for ISR only if the patient has refractory angina.
Can you promise relief from dyspnea
Contemplating PCI for patients with dyspnea as the main symptom is really tricky one.Unlike angina , dyspnoea can be attributed to so many factors other than coronary blood flow.(Apart from LV EF , Iscehmic MR, A transient diastolic dysfunction , lung function , volume status, renal function , physical conditioning etc)
Opening ISR in the belief it would improve LV function is highly questionable even if viability is documented.
What is the most important step in the decision making prior to PCI for ISR ?
* Most important step in ISR management is probably spending sufficient time , involving experts , ” democratically debating” the indication and techniques in your institutional cath conference.
Once you document the necessity of intervention* The following things are possible .
Issues for which we will never ever know the answer !
In future any of the following combination of stents will occur in tackling ISR.
How does the two metals , two drugs in various combinations interact with the tender coronary endothelium ?
Endothelium is an endocrine organ. It has to secrete as many pro and anti homeostatic molecules (Nitric oxide, endothelin etc).This has to be kept in mind when we develop newer and exotic devices. Of course , we claim our aim is primarily to provide relief to our ailing patients , but, as things stand today , there is a distinct risk of converting human coronary arteries into corporate playgrounds !
Reference :
http://circ.ahajournals.org/content/100/18/1872.full.pdf+html
Posted in Cardiology - Clinical, Cardiology -Interventional -PCI, Infrequently asked questions in cardiology (iFAQs), tagged bifurcation lesion, coronary atherosclerosis, drug eluting stents, eccentric plaque, edge effect, europcr, freed, geographical miss, instent restenosis, left main, pci, plaque prolapse, ptca, saian, stent thrombosis, stents, syntax, tct md, what is plaque prolapse on March 20, 2009| Leave a Comment »
Coronary stents have revolutionised the management of CAD. Stents are metallic scaffolding devices that help keep the atherosclerotic plaque plastered within the coronary arterial wall.Thus it gained the name angioplasty. Stents have aradial strength that exerts a constant force on the plaque . Since metals are unfriendly partners for coronary artery , we need to have minimum metal within the coronary artery.The stent struts weave around the lumen generally the stento/ artery area ratio should be as less as possible (15%).
But this has a trade off .The uncovered area of plaque tend to project into the lumen .This is many times not significant.But can be a problem if the plaque is very soft and bulk of the lipid core may reenter the lumen.this event is called plaque prolapse.
Generally it is late event.But it can happen immediately after the procedure also.
Eccentric and complex lesions especially with overhanging edges are prone for prolapse
It can be benign.If there is a erosion due to stent struts can precipitate an ACS.It progresses into instent restnosis in many.
Angiographically it often appears as luminal irregularity withi stented segment .
Many times , it may appear as a filling defect also.
Coornary artery is not drugged uniformly by the drug eluting stents.In fact contact lines of metalic struts , through it’s micropore oozes the drug with polymer.Pathological studies have revelaed non homogenous drug penetration and resultant irregularity on the plaque surface.This could amplify the plaque penetration preferentially in few areas.
It should be managed as any other instent restenosis.Plaque resection with atherectomy devices has not solved the problem to the desired levels.A second stent is the most common approach advocated by the cardiologists.(Whic is not ideal though !)
Dr.S.Venkatesan MD 