Predictive factors of restenosis after coronary stent placement

1. Medizinische Klinik rechts der Isar and Deutsches Herzzentrum, Technische Universitat Munchen, Munich, Germany.

OBJECTIVES: The objective of this study was to identify clinical, lesional and procedural factors that can predict restenosis after coronary stent placement. BACKGROUND: Coronary stent placement reduces the restenosis rate compared with that after percutaneous transluminal coronary angioplasty (PTCA). However, restenosis remains an unresolved issue, and identification of its predictive factors may allow further insight into the underlying process. METHODS: All patients with successful coronary stent placement were eligible for this study unless they had had a major adverse cardiac event during the 1st 30 days after the procedure. Of the 1,349 eligible patients (1,753 lesions), follow-up angiography at 6 months was performed in 80.4% (1,084 patients, 1,399 lesions). Demographic, clinical, lesional and procedural data were prospectively recorded and analyzed for any predictive power for the occurrence of late restenosis after stenting. Restenosis was evaluated by using three outcomes at follow-up: binary restenosis as a diameter stenosis > or =50%, late lumen loss as lumen diameter reduction and target lesion revascularization (TLR) as any repeat PTCA or coronary artery bypass surgery involving the stented lesion. RESULTS: Multivariate analysis demonstrated that diabetes mellitus, placement of multiple stents and minimal lumen diameter (MLD) immediately after stenting were the strongest predictors of restenosis. Diabetes increased the risk of binary restenosis with an odds ratio (OR) [95% confidence interval] of 1.86 [1.56 to 2.16] and the risk of TLR with an OR of 1.45 [1.11 to 1.80]. Multiple stents increased the risk of binary restenosis with an OR of 1.81 [1.55 to 2.06] and that of TLR with an OR of 1.94 [1.66 to 2.22]. An MLD <3 mm at the end of the procedure augmented the risk of binary restenosis with an OR of 1.81 [1.55 to 2.06] and that of TLR with an OR of 2.05 [1.77 to 2.34]. Classification and regression tree analysis demonstrated that the incidence of restenosis may be as low as 16% for a lesion without any of these risk factors and as high as 59% for a lesion with a combination of these risk factors. CONCLUSIONS: Diabetes, multiple stents and smaller final MLD are strong predictors of restenosis after coronary stent placement. Achieving an optimal result with a minimal number of stents during the procedure may significantly reduce this risk even in patients with adverse clinical characteristics such as diabetes.

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				L. Gruberg, R. Waksman, A. E. Ajani, H.-S. Kim, R. L. White, E. E. Pinnow, L. F. Satler, A. D. Pichard, K. M. Kent, and J. Lindsay Jr The effect of intracoronary radiation for the treatment of recurrent in-stent restenosis in patients with diabetes mellitus J. Am. Coll. Cardiol., June 19, 2002; 39(12): 1930 - 1936. [Abstract] [Full Text] [PDF]

				G. Heper, T. Durmaz, S. Namik Murat, and E. Ornek Clinical and Angiographic Outcomes of Diabetic Patients After Coronary Stenting: A Comparison of Native Vessel Stent Restenosis Rates in Different Diabetic Subgroups Angiology, May 1, 2002; 53(3): 287 - 295. [Abstract] [PDF]

				Y. Yoshitomi, S. Kojima, M. Yano, Y. Matsumoto, T. Sugi, M. Saotome, K.-e Tanaka, M. Endo, and M. Kuramochi Peristent Tissue Proliferation of Multilink Stents Is Dependent on Preprocedural Plaque Area: A Serial Intravascular Ultrasound Analysis Angiology, May 1, 2002; 53(3): 303 - 311. [Abstract] [PDF]

				H. Sasao, A. Endo, T. Hasegawa, Y. Ichikawa, R. Noda, H. Oimatsu, and T. Takada Long-Term Follow-up After Coronary Stent Implantation in Patients with Coronary Artery Disease Angiology, March 1, 2002; 53(2): 149 - 156. [Abstract] [PDF]

				P. W. Serruys, D. P. Foley, M.-J. Suttorp, B. J. W. M. Rensing, H. Suryapranata, P. Materne, A. van den Bos, E. Benit, A. Anzuini, W. Rutsch, et al. A randomized comparison of the value of additional stenting after optimal balloon angioplasty for long coronary lesions: Final results of the additional value of nir stents for treatment of long coronary lesions (ADVANCE) study J. Am. Coll. Cardiol., February 6, 2002; 39(3): 393 - 399. [Abstract] [Full Text] [PDF]

				H. C. Lowe, S. N. Oesterle, and L. M. Khachigian Coronary in-stent restenosis: Current status and future strategies J. Am. Coll. Cardiol., January 16, 2002; 39(2): 183 - 193. [Abstract] [Full Text] [PDF]

				E. Erdmann Cardiovascular events in patients with type 2 diabetes The British Journal of Diabetes & Vascular Disease, January 1, 2002; 2(1_suppl): S4 - S8. [Abstract] [PDF]

				P. N. Ruygrok, M. W.I. Webster, V. de Valk, G.-A. van Es, J. A. Ormiston, M.-A. M. Morel, and P. W. Serruys Clinical and Angiographic Factors Associated With Asymptomatic Restenosis After Percutaneous Coronary Intervention Circulation, November 6, 2001; 104(19): 2289 - 2294. [Abstract] [Full Text] [PDF]

				W. R. P. Agema, J. W. Jukema, S. N. Pimstone, and J. J. P. Kastelein Genetic aspects of restenosis after percutaneous coronary interventions;towards more tailored therapy Eur. Heart J., November 2, 2001; 22(22): 2058 - 2074. [PDF]

				R. Hoffmann, C. Jansen, A. Konig, P.K. Haager, G. Kerckhoff, J. Vom Dahl, V. Klauss, P. Hanrath, and H. Mudra Stent design related neointimal tissue proliferation in human coronary arteries; an intravascular ultrasound study Eur. Heart J., November 1, 2001; 22(21): 2007 - 2014. [Abstract] [PDF]

				A. Colombo, J. De Gregorio, I. Moussa, Y. Kobayashi, E. Karvouni, C. Di Mario, R. Albiero, L. Finci, and J. Moses Intravascular ultrasound-guided percutaneous transluminal coronary angioplasty with provisional spot stenting for treatment of long coronary lesions J. Am. Coll. Cardiol., November 1, 2001; 38(5): 1427 - 1433. [Abstract] [Full Text] [PDF]

				N. Mercado, E. Boersma, W. Wijns, B. J. Gersh, C. A. Morillo, V. de Valk, G.-A. van Es, D. E. Grobbee, and P. W. Serruys Clinical and quantitative coronary angiographic predictors of coronary restenosis: A comparative analysis from the balloon-to-stent era J. Am. Coll. Cardiol., September 1, 2001; 38(3): 645 - 652. [Abstract] [Full Text] [PDF]

				M. Adamian, A. Colombo, C. Briguori, T. Nishida, F. Marsico, C. Di Mario, R. Albiero, I. Moussa, and J. W. Moses Cutting balloon angioplasty for the treatment of in-stent restenosis: a matched comparison with rotational atherectomy, additional stent implantation and balloon angioplasty J. Am. Coll. Cardiol., September 1, 2001; 38(3): 672 - 679. [Abstract] [Full Text] [PDF]

				A. Moustapha, A. R. Assali, S. Sdringola, W. K. Vaughn, R. D. Fish, O. Rosales, G. Schroth, Z. Krajcer, R. W. Smalling, and H. V. Anderson Percutaneous and surgical interventions for in-stent restenosis: long-term outcomes and effect of diabetes mellitus J. Am. Coll. Cardiol., June 1, 2001; 37(7): 1877 - 1882. [Abstract] [Full Text] [PDF]

				W. J. Cantor, A. S. Hellkamp, E. D. Peterson, J. P. Zidar, P. A. Cowper, M. H. Sketch Jr, J. E. Tcheng, R. M. Califf, and E. M. Ohman Achieving optimal results with standard balloon angioplasty: can baseline and angiographic variables predict stent-like outcomes? J. Am. Coll. Cardiol., June 1, 2001; 37(7): 1883 - 1890. [Abstract] [Full Text] [PDF]

				D.H Walter, V Schachinger, M Elsner, S Mach, S Dimmeler, W Auch-Schwelk, and A.M Zeiher Statin therapy is associated with reduced restenosis rates after coronary stent implantation in carriers of the PlA2allele of the platelet glycoprotein IIIa gene Eur. Heart J., April 1, 2001; 22(7): 587 - 595. [Abstract] [PDF]

				F Schiele, M K Batur, M F Seronde, N Meneveau, P Sewoke, A Bassignot, G Couetdic, F Caulfield, and J-P Bassand Cytomegalovirus, Chlamydia pneumoniae, and Helicobacter pylori IgG antibodies and restenosis after stent implantation: an angiographic and intravascular ultrasound study Heart, March 1, 2001; 85(3): 304 - 311. [Abstract] [Full Text]

				R. Makkar, J. Whiting, A. Li, H. Honda, M. C. Fishbein, F.F. Knapp, J. Hausleiter, F. Litvack, and N. L. Eigler Effects of {beta}--Emitting 188Re Balloon in Stented Porcine Coronary Arteries : An Angiographic, Intravascular Ultrasound, and Histomorphometric Study Circulation, December 19, 2000; 102(25): 3117 - 3123. [Abstract] [Full Text] [PDF]

				A. Kastrati, W. Koch, P. B. Berger, J. Mehilli, K. Stephenson, F.-J. Neumann, N. von Beckerath, C. Bottiger, G. W. Duff, and A. Schomig Protective role against restenosis from an interleukin-1 receptor antagonist gene polymorphism in patients treated with coronary stenting J. Am. Coll. Cardiol., December 1, 2000; 36(7): 2168 - 2173. [Abstract] [Full Text] [PDF]

				R. Hoffmann and G.S. Mintz Coronary in-stent restenosis--predictors, treatment and prevention Eur. Heart J., November 1, 2000; 21(21): 1739 - 1749. [PDF]

				T. Takagi, T. Akasaka, A. Yamamuro, Y. Honda, T. Hozumi, S. Morioka, and K. Yoshida Troglitazone reduces neointimal tissue proliferation after coronary stent implantation in patients with non-insulin dependent diabetes mellitus: A serial intravascular ultrasound study J. Am. Coll. Cardiol., November 1, 2000; 36(5): 1529 - 1535. [Abstract] [Full Text] [PDF]