New approaches to preventing restenosis

• Published in: BMJ Vol. 327; no. 7409; pp. 274 - 279
• Main Authors: Bhargava, Balram, Karthikeyan, Ganesan, Abizaid, Alexandre S, Mehran, Roxana
• Format: Journal Article
• Language: English
• Published: London British Medical Journal Publishing Group 02.08.2003; British Medical Association; BMJ Publishing Group LTD; BMJ Publishing Group; BMJ Group
• Edition: International edition
• Subjects: Acute coronary syndromes; Angina pectoris; Angioplasty; Atherectomy, Coronary - methods; Balloon angioplasty; Balloons; Biological and medical sciences; Blood platelets; Brachytherapy; Brachytherapy - methods; Cardiology. Vascular system; Cardiovascular Agents - therapeutic use; Cardiovascular disease; Catheterization - methods; Cell cycle; Cell division; Clinical Review; Coronary atherectomy; Coronary heart disease; Coronary restenosis; Coronary Restenosis - prevention & control; Coronary vessels; Diabetes; Disease; Drug dosages; Drug Implants; Gene expression; Genetic Therapy - methods; Growth factors; Heart; Heart attacks; Heart surgery; Humans; Lesions; Medical sciences; Percutaneous transluminal coronary angioplasty; Radiation therapy; Smooth muscle; Smooth muscle myocytes; Stents; Thrombosis; United States > US; Human; Prevention; Restenosis; Cardiovascular disease; Review; Coronary heart disease
• ISSN: 0959-8138; 0959-8146; 1468-5833; 1756-1833
• DOI: 10.1136/bmj.327.7409.274

Year and procedure Indications Restenosis rate (%) New problem Solution 1977-87: percutaneous transluminal coronary angioplasty Simple lesions, chronic syndromes 30-50 Restenosis, subacute closure Stent 1988-92: - - - - Newer devices-Rotablater, excimer laser coronary angioplasty, directional coronary atherectomy Complex, calcific, tortuous, bifurcations, left main, multiple lesions 50 Restenosis; restenosis 50-70% Intravascular ultrasound guided use Stents Acute coronary syndromes 20-30 Restenosis, subacute thrombosis, instent restenosis High pressure, anticoagulation 1993-2002: newer stents (biodegradable, covered, radioactive, intravascular ultrasonography) Carotids, iliacs, renals, saphenous vein grafts, abdominal aortic aneurysms direct, rupture 10-20 Instent restenosis, re-restenosis 50-70% Improved designs and material, radiation 1995-2002: brachytherapy-photodynamic therapy, ultrasonography, cryotherapy, cutting balloon Instent restenosis <10 Restenosis, re-restenosis 10% late thrombosis, edge failure, geographical miss Prolonged antiplatelets 2002: eluting stents-drugs, gene Simple lesions, chronic syndromes, some complex lesions 0-5 ? Summary points Restenosis is a common problem after percutaneous coronary interventions, depending on patient characteristics, lesion morphology, and the type of intervention Coronary stenting is the only intervention that has reliably and consistently reduced restenosis in coronary lesions Near zero per cent restenosis rates have recently been achieved with antiproliferative drug eluting coronary stents Recurrent stenosis after treatment of instent restenosis is common Adjuvant treatment with intracoronary [GAMMA] and β radiation is the most effective currently available means to prevent recurrent stenosis after the treatment of instent restenosis Modifying gene expression using antisense therapies or gene transfer will play an important part in the prevention of restenosis Box 1 Evolution of percutaneous interventions Phase 1 (1977-87): simple balloon angioplasty Phase 2 (1988-92): new device angioplasty Phase 3 (1993-2002): stent revolution Clinically significant restenosis generally occurs between one and three months after balloon angioplasty.