CAD: In-Stent Restenosis

Overview

What is Restenosis?

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).

Management and Treatment

What are the treatment options for in-stent restenosis?

Re-stenting

If an interventional procedure is needed, the approach will vary depending on if the original stent(s) were fully expanded, how many stents are overlapped, and the length of the re-blockage.

Non-Surgical Options

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. This can be done with a high pressure balloon (sometimes assisted by laser to loosen up the firm tissue around 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). However, the risk of reblockage increases with the number of overlapping stents. If 2-3 stents are already in place, we usually recommend brachytherapy or occasionally drug-eluting balloon use. Shorter blockages tends to respond better to all of these approaches.

Supplementary Medications

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.

Medical Management

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.

Surgery

Bypass Surgery

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.

What are the treatment options for patients with a complete blockage (Total Coronary Occlusion)?

Percutaneous Techniques

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).

Retrograde Approach

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.

Outlook / Prognosis

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.

Living With

Lifestyle Changes

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.

Resources

Center for Complex Coronary Interventions

Cleveland Clinic’s Center for Complex Interventions offers comprehensive treatment for patients with complex coronary artery disease.

Specialists from interventional cardiology tailor individual approaches for their patients.

When you come to Cleveland Clinic’s Center for Complex Interventions, you will receive care from some of the leading specialists in the world. Many of our physicians participate in the research and development of the newest treatments.

Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.

Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, please review our Miller Family Heart, Vascular & Thoracic Institute Outcomes.

Cleveland Clinic Heart, Vascular & Thoracic Institute Cardiologists and Surgeons

Choosing a doctor to treat your coronary artery disease depends on where you are in your diagnosis and treatment.

Click on the following links to learn more about Sections and Departments treat patients with Coronary Artery Disease:

The Miller Family Heart, Vascular & Thoracic Institute offers specialty centers and clinics for patients whose treatment requires the expertise of a group of doctors and surgeons who fous on a specific condition.

See: About Us to learn more about the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute.

Contact

If you need more information, click here to contact us, chat online with a nurse or call the Miller Family Heart, Vascular & Thoracic 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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Diagnostic Tests

Diagnostic tests are used to diagnose coronary artery disease and the most effective treatment method.

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Our outcomes speak for themselves. Please review our facts and figures and if you have any questions don't hesitate to ask.

Last reviewed by a Cleveland Clinic medical professional on 05/01/2019.

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Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy