What are the treatment options for in-stent restenosis?
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.
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.
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.
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.
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)?
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.