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CLINICAL STUDY: INTERVENTIONAL CARDIOLOGY

Percutaneous and surgical interventions for in-stent restenosis: long-term outcomes and effect of diabetes mellitus

Ali Moustapha, MD^*, Abid R. Assali, MD^*, Stefano Sdringola, MD^*, William K. Vaughn, PhD, R. David Fish, MD, FACC, Oscar Rosales, MD, FACC^*, George Schroth, MD, FACC^*, Zvonimir Krajcer, MD, FACC, Richard W. Smalling, MD, PhD, FACC^* and H. Vernon Anderson, MD, FACC^*

^* University of Texas Medical School at Houston, Houston, Texas, and Memorial Hermann Hospital, Houston, Texas, USA
Texas Heart Institute, Houston, Texas, and St. Luke’s Episcopal Hospital, Houston, Texas, USA

Manuscript received September 12, 2000; revised manuscript received February 1, 2001, accepted February 15, 2001.

Reprint requests and correspondence: Dr. H. Vernon Anderson, University of Texas Medical School at Houston, MSB 1.246, 6431 Fannin, Houston, Texas 77030
h.v.anderson{at}uth.tmc.edu

OBJECTIVE

We examined long-term outcomes of patients with in-stent restenosis (ISR) who underwent different percutaneous interventions at the discretion of individual operators: balloon angioplasty (BA), repeat stent or rotational atherectomy (RA). We also examined long-term outcomes of patients with ISR who underwent coronary artery bypass surgery (CABG).

BACKGROUND

In-stent restenosis remains a challenging problem, and its optimal management is still unknown.

METHODS

Symptomatic patients (n = 510) with ISR were identified using cardiac catheterization laboratory data. Management for ISR included BA (169 patients), repeat stenting (117 patients), RA (107 patients) or CABG (117 patients). Clinical outcome events of interest included death, myocardial infarction, target vessel revascularization (TVR) and a combined end point of these major adverse cardiovascular events (MACE). Mean follow-up was 19 ± 12 months (range = 6 to 61 months).

RESULTS

Patients with ISR treated with repeat stent had significantly larger average post-procedure minimal lumen diameter compared with BA or RA (3.3 ± 0.4 mm vs. 3.0 ± 0.4 vs. 2.9 ± 0.5, respectively, p < 0.05). Incidence of TVR and MACE were similar in the BA, stent and RA groups (39%, 40%, 33% for TVR and 43%, 40%, 33% for MACE, p = NS). Patients with diabetes who underwent RA had similar outcomes as patients without diabetes, while patients with diabetes who underwent BA or stent had worse outcomes than patients without diabetes. Patients who underwent CABG for ISR, mainly because of the presence of multivessel disease, had significantly better outcomes than any percutaneous treatment (8% for TVR and 23% for MACE).

CONCLUSIONS

In this large cohort of patients with ISR and in the subset of patients without diabetes, long-term outcomes were similar in the BA, repeat stent and RA groups. Tissue debulking with RA yielded better results only in diabetic patients. Bypass surgery for patients with multivessel disease and ISR provided the best outcomes.

Abbreviations and Acronyms   BA = balloon angioplasty   CABG = coronary artery bypass graft surgery   ISR = in-stent restenosis   LAD = left anterior descending artery   MACE = major adverse cardiovascular events   MI = myocardial infarction   MLD = minimal lumen diameter   RA = rotational atherectomy   TVR = target vessel revascularization

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