Dr. Ellis, head of Invasive and Interventional Cardiology and Director of the Cleveland Clinic’s Sones Cardiac Catheterization Laboratories, responds to this question that his patients often ask him:
"What are the treatment options for restenosis that occurs at the site of a previously implanted stent?”
There are many treatment options for blockages that occur at the site where a stent was placed. The first step is to meet with an experienced cardiac interventionalist who can tailor a treatment approach based on the location of the blocked stent, extent of the blockage, the patient’s age, type of cardiovascular disease and coexisting medical conditions. A number of things need to be considered.
Is the artery totally blocked?
First, the interventionalist should determine whether or not angioplasty equipment can even be placed across the blockage, depending on the location and severity of the blockage. If the stent is not totally blocked, the interventionalist is often able to access the blockage using traditional percutaneous techniques.
What are options for totally blocked arteries (total coronary occlusion)?
If the stent is totally blocked, alternate percutaneous techniques may be used by experienced interventionalists to access the blockage and considerably improve the success rate of this treatment approach. Special guide wires and catheters can be gently steered across the total blockages. The fine movement of new guide wire tips is much easier to control than previous guide wire tips. Success rates approach 80%. In addition, Cleveland Clinic interventionalists can use the "retrograde" approach, in which total coronary blockages are accessed from collateral blood vessels. Collateral blood vessels are new blood vessels that form to reroute blood flow around a blockage, and develop when the blockage becomes severely narrowed.
In some cases when the blockage cannot be accessed surgery may be recommended.
Has the blockage occurred where a bare metal stent was placed?
To treat a blockage that has occurred at the site of an uncoated, bare metal stent, placement of a drug-eluting stent (for eligible patients) often provides a very satisfactory long-term outcome.
If the blockage is short, sometimes balloon angioplasty or cutting balloon angioplasty are enough to effectively treat the blockage.
Balloon angioplasty is a procedure in which a small balloon at the tip of the catheter is inserted near the blocked or narrowed area of the coronary artery. When the balloon is inflated, the scar tissue of the blockage is compressed against the artery walls and the diameter of the blood vessel is widened (dilated) to increase blood flow to the heart.
The cutting balloon catheter has a balloon tip with small blades. When the balloon is inflated, the blades are activated. The small blades score the plaque, and the balloon expands the previously placed stent .
Has the blockage occurred where a drug-eluting stent was placed?
Determine proper placement. First, it is important to know if the stent was actually placed and expanded properly. An intravascular ultrasound examination can help determine if the stent was properly deployed. If the stent wasn't properly placed, sometimes simply re-expanding it is all that is needed. If the stent was well-expanded and tissue regrowth has occurred within the stent, using a different type of drug-eluting stent is generally the best option.
Review the type of drug eluting stent used. If a Sirolimus – type (Cypher, Xience, Endeavor) drug eluting stent was used, the physician will consider a Taxus stent (delivers paclitaxel). If a Taxus stent was used, the physician will consider a Sirolimus analog delivering stent.
Long-term anticoagulation therapy. Almost all coronary interventional procedures involve the use of stents. Until the artery around the stent has healed there is a risk of blood clots forming on the metal. With bare metal stents, clopidigrel needs to be taken for at least 4 weeks and with DES, at least a year. Randomized trials are ongoing to better clarify the optimal duration of clopidigrel and related medications. In addition, in some patients prasugrel may be a better choice than clopidogrel. Talk to your doctor about the latest information about this choice. Aspirin is known to reduce the risk of heart attack in anybody with coronary artery disease bad enough to require a stent and should be taken indefinitely.
Consider bypass surgery as treatment options.
Coronary artery bypass graft surgery is a treatment in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient’s own arteries and veins located in the chest, leg or arm. The graft goes around the blocked artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart.
An experienced team of cardiologists and surgeons can evaluate your cardiac catheterization and medical history to determine the best option to treat restenosis.
While restenosis that occurs at the site of a previously implanted stent can be a challenging condition to treat, experienced interventionalists who are familiar with multiple treatment options can often provide you with a treatment option that has a high likelihood of success.
For more information:
- Holmes, DR, et al. Sirolimus-Eluting Stents vs Vascular Brachytherapy for In-Stent Restenosis Within Bare-Metal Stents. JAMA. 2006;295:1264-1273.
- Smith, SC, Jr, et al. “Management Strategies for Restenosis After PTCA,” from ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention. American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions. Circulation. 2006;113:156-75. http://circ.ahajournals.org/cgi/content/full/113/1/156
- Stone GW, Ellis SG, O'Shaughnessy CD, et al. A prospective, multicenter, randomized trial evaluating the TAXUS paclitaxel-eluting coronary stent versus vascular brachytherapy for the treatment of bare metal stent in-stent restenosis: the TAXUS-V ISR trial. Program and abstracts from the Innovation in Intervention i2 Summit 2006; March 11-14, 2006; Atlanta, Georgia. Abstract 2402-9.
- Stone GW, Ellis SG, O'Shaughnessy CD, et al. Paclitaxel-eluting stents vs vascular brachytherapy for in-stent restenosis within bare-metal stents: the TAXUS V ISR randomized trial. JAMA. 2006;295:1253-1263
If you need more information or would like to make an appointment with a specialist, click here to contact us , chat online with a nurse or call the Miller Family Heart and Vascular Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.
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