Placement and Expansion of the stent
It is possible that the stent was not put in place correctly or that it did not expand the way it should have. An IVUS or OCT can help check to see if either of those problems exist. If so, sometimes the solution is simply re-expanding the stent. If the stent was well-expanded and the problem is tissue regrowth inside the stent, the best treatment option is often placement of another drug-eluting stent (DES).
Drug eluting stent (DES)
If the patient was originally treated with a bare metal stent and the area is blocked, putting a DES in its place (for eligible patients) often provides a good long-term outcome.
If a DES was originally used, the best treatment depends on the type of blockage that has formed. If the area of blockage is very short, sometimes the best treatment is keeping the stent in place and using balloon angioplasty or cutting balloon angioplasty to clear the blockage. If the area of blockage is longer and the patient has not had restenosis before, another DES is usually the best solution, But, if the blockage has recurred several times or if there are multiple blockages, bypass surgery may be needed.
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 pushed against the artery walls. This causes the blood vessel to become wider (dilated) and allow more 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 cut into the plaque to break it up, and the balloon expands.
Brachytherapy uses radiation to keep scar tissue from building up in the stent again. Brachytherapy is done at the same time as angioplasty. After the doctor completes the angioplasty, another catheter with a “ribbon” of radioactive particles (isotopes) is guided to the blockage. The ribbon stays in place for about 4 minutes, and then the catheters are removed.
Brachytherapy is only performed at a few centers in the United States, including Cleveland Clinic.
An experimental treatment that may be an option for some patients is angioplasty using a balloon coated with medication (Paclitaxel).This treatment to clear the blockage and prevent further restenosis is not yet approved in the United States. But, studies suggest that this technique works as well as placing another DES.
Some patients may benefit from taking the oral form of sirolimus (the drug used on the first DES) or cilostazol. Although these drugs often cause side effects, they can help reduce the amount of restenosis tissue that builds up. The medication is sometimes prescribed for patients who have had restenosis more than twice in the same area.
Coronary artery bypass graft surgery uses blood vessels from other parts of the body to make grafts that move blood around the blocked areas of the coronary arteries. The treatment restores normal blood flow to the heart. The grafts come from the patient’s own arteries and veins in the chest, leg or arm. The grafts create new pathways for oxygen-rich blood to flow to the heart. Bypass surgery is a good treatment option for patients (especially patients with diabetes) who have coronary restenosis.
Medications and lifestyle changes may be used to treat some patients with coronary restenosis. The goal of treatment is to control symptoms of coronary artery disease and slow down or stop the disease from getting worse.
Treatment Options for Patients with a Complete Blockage (Total Coronary Occlusion)
If the stent is totally blocked, a percutaneous technique (done through an opening in the skin, not an open incision) may be done. Special guide wires and catheters are used to check the extent of the blockage and clear the area. These special tools along with experience using them also help improve the chance of a successful treatment (near 80% success).
Cleveland Clinic interventionalists can use the "retrograde" approach to move blood around the blocked area. This treatment involves the use of collateral blood vessels. These are new blood vessels that form when the blocked area is severely narrowed.
If you need more information, 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.
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