The Clinical Spectrum and Management of Patients with Coronary In-Stent Restenosis

Document Type : Original Article

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The Department of Cardiovascular Medicine, Faculty of Medicine, Cairo* and Benha** Universities

Abstract

Background: In-stent restenosis (ISR) is a common clini-cal problem that continues to be one of the most important limitations of percutaneous coronary intervention (PCI). It is associated with significant morbidity and costs, and is not a benign entity, with a wide spectrum of clinical presentation. Aim of Study: To detect the prevalence of ISR in a tertiary referral center carried out for patients presented to AL-Nahda General Hospital at Taif, Kingdom of Saudia Arabia and un-derwent clinically driven coronary angiography with a history of previous PCI. Those with missed procedural data related to the previous PCI were excluded from the study. Material and Methods: This was a retrospective- prospec-tive study carried out on patients presented to AL-Nahda Gen-eral Hospitals from November 2018 to November 2019 (350 patients records as a total coverage, 100 were collected as eli-gible) who underwent coronary angiography with a history of previous PCI. Results: Among the studied population, males were 68 (68%) and females were 32 (32%). Mean age was 53±10. Out of 100 patients, in-stent restenosis (ISR) was documented in fifty (50%) patients (45 males and 5 females) and not docu-mented in fifty (50%) patients (27 males - 23 females). The statistical differences were; male gender[90% versus 46%, respectively; p-value <0.001), DM (72% versus 38%, respec-tively; p-value <0.001), Pre and post stenting balloon dilatation [16% versus 2%, respectively; p-value = 0.031), LAD lesion (52% versus 10%, respectively; p-value = 0.002), pre-stent minimal lumen diameter (MLD) (p-value <0.01); the stents in the patients with ISR were smaller in diameter and longer in length. The ISR group was then subdivided according to the lesions characters of in-stent restenosis into two groups: Focal group (22 male - 5 female) and non-focal (Diffuse Prolifera-tive) (23 male - 0 female). Diffuse-type ISR was more com-mon in LAD and RCA lesions 78.3% and 56.5% respectively with (p-values were 0.0001 and 0.028 respectively). During the previous procedure the use of balloon for pre and post stent dilatation was higher in the diffuse-type ISR with statisti-cally significant difference, p-value ≤0.010. The diameter of the stents in ISR patients was small in the diffuse-type ISR (stent diameter was 2.62±0.56 mm in the diffuse-type ISR and 3.04±0.31mm in the focal group, with statistically significant difference, p-value ≤0.002) and the stents length was longer in the diffuse-type ISR (29.35±9.26mm) versus (22.11±7.91mm), with statistically significant difference (p-value ≤0.005). Dur-ing the follow up the diffuse type was associated with more complications and one case mortality. Conclusion: A number of factors have been associated with the propensity to develop stent restenosis, including male gender, diabetes mellitus, LAD lesion, small stent diameter, in-creased stent length; balloon used pre or post stenting and pre-stenting MLD which were all predictors of restenosis in this study. Diabetes mellitus, stent length and pre stenting minimal lumen diameter (MLD) were independent predictors of ISR. This study also showed that pre-stenting MLD, pre and post stenting balloon dilatation, DM, Male sex, LAD, RCA, and the stent length and diameter are predictors of diffuse (non-focal) type ISR.

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