Routine sirolimus eluting stent implantation for unselected in-stent restenosis: insights from the rapamycin eluting stent evaluated at Rotterdam Cardiology Hospital (RESEARCH) registry

Abstract

Objective: To assess the effectiveness of routine sirolimus eluting stent (SES) implantation for unselected patients with in-stent restenosis and to provide preliminary information about the angiographic outcome for lesion subgroups and for different in-stent restenosis patterns.

Design: Prospective, single centre registry.

Setting: Tertiary referral centre.

Patients: 44 consecutive patients (53 lesions) without previous brachytherapy who were treated with SES for in-stent restenosis were evaluated. Routine angiographic follow up was obtained at six months and the incidence of major adverse cardiovascular events was evaluated.

Results: At baseline, 42% of the lesions were focal, 21% diffuse, 26% proliferative, and 11% total occlusions. Small vessel size (reference diameter < or = 2.5 mm) was present in 49%, long lesions (> 20 mm) in 30%, treatment of bypass grafts in 13%, and bifurcation stenting in 18%. At follow up, post-SES restenosis was observed in 14.6%. No restenosis was observed in focal lesions. For more complex lesions, restenosis rates ranged from 20-25%. At the one year follow up, the incidence of death was 0, myocardial infarction 4.7% (n = 2), and target lesion revascularisation 16.3% (n = 7). The target lesion was revascularised because of restenosis in 11.6% (n = 5).

Conclusions: Routine SES implantation is highly effective for focal in-stent restenosis and appears to be a promising strategy for more complex patterns of restenosis.

Figure 1

Sirolimus eluting stent (SES) implantation for total occlusion due to in-stent restenosis: representative sequences of angiograms from two patients. Patient 1: (A) Diagnostic angiogram showing total occlusion of the proximal right coronary artery due to in-stent restenosis (arrows). (B) Final result after implantation of two overlapping SES, 3 × 18 mm proximal (1), and 3 × 33 mm distal (2). Some minimal residual stenosis is visible at the distal stent edge. (C) Six month angiographic follow up showing persistence of the good result obtained previously. Patient 2: (D) Diagnostic angiogram showing in-stent restenosis giving total occlusion of the mid part of the left anterior descending artery (LAD) (arrows), immediately after the origin of the second diagonal branch. (E) Final result after implantation of three overlapping SES in the LAD, 2.75 × 8 mm proximal (3), 2.5 × 33 mm in the middle (4), and 2.25 × 8 mm distal (5). Bifurcation stenting was necessary to preserve the second diagonal (6, SES 2.25 × 8 mm). (F) Six month angiographic follow up showing persistence of the good result in both vessels.

Figure 2

Cumulative distribution of late loss at angiographic follow up. Lesions with binary restenosis are indicated by empty squares. Clinical outcome of each restenotic lesion is reported corresponding to the respective late loss value. This curve resembles a bimodal distribution and suggests that the failed cases may share unique features. Med tx, medical treatment; TLR, target vessel revascularisation; TO, total occlusion.