Restenosis means that a section of blocked artery that was opened up with angioplasty or a stent has become narrowed again.
There are many treatment options for patients who have restenosis after receiving a stent. The first step in treatment is meeting with an experienced cardiac interventionist (a doctor who performs procedures to open up clogged arteries). The doctor can determine the best type of treatment based on the location of the blocked stent, how badly it is blocked, and information about the patient (such as age, type of cardiovascular disease, and other medical conditions). The doctor will perform a catheterization and can use tests during the procedure to get more information about the blockage by looking inside the artery. These tests include intravascular ultrasound (IVUS) and optical coherence tomography (OCT).
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.
After Your Procedure
Long-Term Antiplatelet Therapy. Almost all coronary interventional procedures involve the use of stents. Until the artery around the stent is healed, there is a risk of blood clots forming on the metal. Patients who have bare metal stents need to take antiplatelet medication for at least 4 weeks after the procedure. Patients who have a drug-eluting stent need to take antiplatelet medication for at least a year after the procedure, and longer for high risk patients. There are several types of this medication. The most common are clopidogrel (Plavix), prasugrel (Effient) and ticagrelor (Brilinta). Patients will likely need to also take daily aspirin to reduce the risk of a heart attack. Do not start or stop taking any medication without first talking to your doctor.
A healthy lifestyle is an important part of avoiding future restenosis and helping the success of treatment. Patients who have treatment for restenosis should:
Let us know if you need any information or tips to help you with your healthy lifestyle. Your healthcare team can help you achieve your goals, but it is up to you to be an active member of the treatment team. Ask your doctor about cardiac rehabilitation to help you learn more about reducing your risk of heart disease.
If you or someone you know has restenosis, it is important to find a center that has experienced doctors who are able to provide you with a broad range of treatment options. Cleveland Clinic’s cardiac interventionalists have extensive experience in treating patients with restenosis. They provide very successful outcomes to patients, even those with the most complex medical conditions.
For more information:
Byrne RA, Neumann FJ, Mehilli J, Pinieck S, Wolff B, Tiroch K, Schulz S, Fusaro M, Ott I, Ibrahim T, Hausleiter J, Valina C, Pache J, Laugwitz KL, Massberg S, Kastrati A; ISAR-DESIRE 3 investigators. Paclitaxel-eluting balloons, paclitaxel-eluting stents, and balloon angioplasty in patients with restenosis after implantation of a drug-eluting stent (ISAR-DESIRE 3): a randomised, open-label trial. Lancet. 2013; Feb 9;381(9865):461-7. doi: 10.1016/S0140-6736(12)61964-3. Epub 2012 Dec 1.
Ellis SG, O'Shaughnessy CD, Martin SL, Kent K, McGarry T, Turco MA, Kereiakes DJ, Popma JJ, Friedman M, Koglin J, Stone GW; TAXUS V ISR Investigators. Two-year clinical outcomes after paclitaxel-eluting stent or brachytherapy treatment for bare metal stent restenosis: the TAXUS V ISR trial. Eur Heart J. 2008;Jul;29(13):1625-34. doi: 10.1093/eurheartj/ehn231. Epub 2008 Jun 13.
Habara S, Mitsudo K, Kadota K, Goto T, Fujii S, Yamamoto H, Katoh H, Oka N, Fuku Y, Hosogi S, Hirono A, Maruo T, Tanaka H, Shigemoto Y, Hasegawa D, Tasaka H, Kusunose M, Otsuru S, Okamoto Y, Saito N, Tsujimoto Y, Eguchi H, Miyake K, Yoshino M. Effectiveness of paclitaxel-eluting balloon catheter in patients with sirolimus-eluting stent restenosis. JACC Cardiovasc Interv. 2011;Feb;4(2):149-54. doi: 10.1016/j.jcin.2010.10.012.
Holmes DR Jr, Teirstein P, Satler L, Sketch M, O’Malley J, Pompa JJ, Kuntz RE, Fitzgerald PJ, Wang H, Caramanica E, Cohen SA; SISR Investigators. Sirolimus-eluting stents vs vascular brachytherapy for in-stent restenosis within bare-metal stents: the SISR randomized trial. JAMA. 2006;Mar 15;295(11):1264-73. Epub 2006 Mar 12.
Rittger H, Brachmann J, Sinha AM, Waliszewski M, Ohlow M, Brugger A, Thiele H, Birkemeyer R, Kurowski V, Breithardt OA, Schmidt M, Zimmermann S, Lonke S, von Cranach M, Nguyen TV, Daniel WG, Wöhrle J. A randomized, multicenter, single-blinded trial comparing paclitaxel-coated balloon angioplasty with plain balloon angioplasty in drug-eluting stent restenosis: the PEPCAD-DES study. J Am Coll Cardiol. 2012;Apr 10;59(15):1377-82. doi: 10.1016/j.jacc.2012.01.015. Epub 2012 Feb 29.
Scheller B, Clever YP, Kelsch B, Hehrlein C, Bocksch W, Rutsch W, Haghi D, Dietz U, Speck U, Böhm M, Cremers B. Long-term follow-up after treatment of coronary in-stent restenosis with a paclitaxel-coated balloon catheter. JACC Cardiovasc Interv. 2012;Mar;5(3):323-30. doi: 10.1016/j.jcin.2012.01.008.
Singh IM, Filby SJ, El Sakr F, Gorodeski EZ, Lincoff AM, Ellis SG, Shishehbor MH. Drug-eluting stents versus bare-metal stents for treatment of bare-metal in-stent restenosis. Catheter Cardiovasc Interv. 2010;Aug 1;76(2):257-62. doi: 10.1002/ccd.22509.
Smith, SC, Jr, Feldman TE, Hirshfeld JW Jr, Jacobs AK, Kern MJ, King SB 3rd, Morrison DA, O’Neil WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology/ American Heart Association Task Force on Practice Guidelines; ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention. ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation. 2006;Jan3;113(1):156-75. http://circ.ahajournals.org/cgi/content/full/113/1/156.
Stone GW, Ellis SG, O'Shaughnessy CD, Martin SL, Satler L, McGarry T, Turco MA, Kereiakes DJ, Kelley L, Popma JJ, Russell ME; TAXUS V ISR Investigators. Paclitaxel-eluting stents vs vascular brachytherapy for in-stent restenosis within bare-metal stents: the TAXUS V ISR randomized trial. JAMA. 2006;Mar 15; 295(11):1253-1263. Epub 2006 Mar 12.
Torguson R, Sabate M, Deible R, Smith K, Chu WW, Kent KM, Pichard AD, Suddath WO, Satler LF, Waksman R. Intravascular brachytherapy versus drug-eluting stents for the treatment of patients with drug-eluting stent restenosis. Am J Cardiol. 2006;Nov 15;98(10):1340-4. Epub 2006 Sep 26.