Switching types of drug-eluting stents does not prevent repeated in-stent restenosis in patients with coronary drug-eluting stent restenosis

Abstract

Objectives: We treated patients experiencing drug-eluting stent (DES) restenosis with plain old balloon angioplasty (POBA), implantation of the same type of DES [homogeneous drug-eluting stent (HOMO-DES)], or implantation of a different type of DES [heterogeneous drug-eluting stent (HETERO-DES)], and compared the efficacy and safety of these procedures for the prevention of repeated in-stent restenosis (ISR).

Background: In patients with de-novo coronary lesions, DES implantation is associated with a markedly reduced restenosis rate as compared with that associated with a bare metal stent and POBA. However, the optimal management strategy for patients with DES ISR remains unknown.

Patients and methods: We identified 191 consecutive DES ISR lesions from 183 patients who required clinically driven revascularization and divided them into three groups according to the treatment: 38 lesions were treated with POBA, 38 with HOMO-DES, and 115 with HETERO-DES.

Results: The incidence of target lesion revascularization (TLR) was 42.1% (16/38), 15.8% (6/38), and 16.5% (19/115) in the POBA, HOMO-DES, and HETERO-DES groups (POBA vs. HOMO, HETERO-DES; P=0.002, respectively). Multivariate analysis indicated that diabetes [odds ratio (OR), 3.4], hemodialysis (OR, 7.74), nonfocal ISR patterns (OR, 3.35), previous myocardial infarction (OR, 3.26), and POBA (OR, 8.84) were independent predictors of TLR.

Conclusion: A strategy involving repeated DES implantation was superior to POBA for preventing recurrent restenosis. Treatment with a different type or generation of DES does not appear to reduce the incidence of TLR. Moreover, we identified certain useful factors for facilitating appropriate and early triage in the patients with repeated DES ISR.

Fig. 1

The predominant target lesion revascularization (TLR) pattern, according to Mehran’s classification, was focal (Type I) and this pattern is associated with a lower incidence of TLR. P<0.001.

Fig. 2

Impact of drug-eluting stent generation on target lesion revascularization (TLR). Switching the generation of drug-eluting stent did not contribute toward a reduction in TLR. No statistical differences were noted in the patients in whom the generation of drug-eluting stents was switched. P=0.86.

Fig. 3

Major adverse cardiac event (MACE)-free survival curve. The repeated use of drug-eluting stent may be more effective and safe than POBA for the prevention of recurrent restenosis. MACE included death, acute myocardial infarction, admission for recurrent angina pectoris, and target lesion revascularization. The POBA group showed the highest MACE rates of the three groups. HETERO, implantation of a different type of drug-eluting stent (heterogeneous); HOMO, implantation of the same type of drug-eluting stent (homogeneous); POBA, plain old balloon angioplasty.