Femoropopliteal in-stent restenosis: current treatment strategies.
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Nitinol self-expanding stents are increasingly used to treat symptomatic peripheral arterial disease. Despite reduction in procedural complications and rates of stent fracture, femoropopliteal in-stent restenosis (FP-ISR) remains a common and important clinical problem. Due to heterogenous patient and angiographic characteristics, treatment of FP-ISR continues to evolve. Multiple modalities have been evaluated including standard balloon angioplasty, cutting or scoring balloon angioplasty, repeat stenting (nitinol stent vs. stent-graft vs. drug eluting stent), excisional or laser atherectomy, drug coated balloon angioplasty, and atherectomy followed by drug coated balloon angioplasty. This review highlights the clinical evidence for the currently available modalities in the treatment of FP-ISR. Future studies should utilize uniform classification schemes and assess similar outcomes to help determine the optimal approach for endovascular treatment of FP-ISR.Keywords:
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Objective:To evaluate the effect of cutting balloon pre dilation on stent restenosis.Methold:Eighty six patients with Multi link stent were randomized into two groups, cutting balloon angioplasty group (CBA) and plain old balloon angioplasty group (POBA). Stent restenosis was identified by coronary angiography after coronary stents placement 6 months.Result:The inner diameter reduced indexes were lower in CBA group than that in POBA group ( 0.28 ± 0.15 vs 0.42 ± 0.28 ,P 0.05 ). The restenosis rate was reduced in CBA group ( 15.4 % vs 25.0 %), but there was no statistical difference.Conclusion: Cutting balloon pre dilation may make a beneficial effect on stent restenosis.
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The optimal treatment for renal artery in-stent restenosis (ISR) is not well established. Reintervention with different strategies including balloon angioplasty, cutting-balloon angioplasty, additional stenting with bare-metal, drug-eluting or covered stents and brachytherapy are effective in achieving immediate angiographic success. However, recurrent ISR rates are high irrespective of treatment strategy. We present a case describing the use of a covered stent for the treatment of recurrent bilateral renal artery ISR after bare-metal and drug-eluting stent implantation and cutting-balloon angioplasty.
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In-stent restenosis remains a clinical therapeutic challenge. Rotational atherectomy (RA) is an attractive treatment option as it may cause less vascular injury than balloon angioplasty (BA) and, therefore, limit further neointimal response. In an animal model of coronary in-stent restenosis, thermal injury and stenting created neointima (old NI). The treatment of in-stent restenosis with either BA (n = 9) or RA (n = 11) also generated neointima (new NI). The average areas (mm2) of old NI in the BA and RA groups were similar (3.77 ± 0.40 vs. 3.67 ± 0.53; P = 0.32). However, new NI formed after treatment of in-stent restenosis was significantly less in the RA as compared to the BA group (0.33 ± 0.12 vs. 0.73 ± 36, P < 0.01). In this porcine coronary artery model of in-stent restenosis, treatment with rotational atherectomy resulted in significantly less recurrent neointimal hyperplasia than balloon angioplasty. This animal study, thus, provides a rationale for the clinical use of rotablation in the treatment of in-stent restenosis. Cathet. Cardiovasc. Diagn. 45:332–336, 1998. © 1998 Wiley-Liss, Inc.
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Nitinol self-expanding stents are increasingly used to treat symptomatic peripheral arterial disease. Despite reduction in procedural complications and rates of stent fracture, femoropopliteal in-stent restenosis (FP-ISR) remains a common and important clinical problem. Due to heterogenous patient and angiographic characteristics, treatment of FP-ISR continues to evolve. Multiple modalities have been evaluated including standard balloon angioplasty, cutting or scoring balloon angioplasty, repeat stenting (nitinol stent vs. stent-graft vs. drug eluting stent), excisional or laser atherectomy, drug coated balloon angioplasty, and atherectomy followed by drug coated balloon angioplasty. This review highlights the clinical evidence for the currently available modalities in the treatment of FP-ISR. Future studies should utilize uniform classification schemes and assess similar outcomes to help determine the optimal approach for endovascular treatment of FP-ISR.
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Abstract Despite the increasing use of percutaneous transluminal coronary angioplasty and intracoronary stent placement for the treatment of obstructive coronary artery disease, a large subset of coronary lesions cannot be adequately treated with balloon angioplasty and/or intracoronary stenting alone. Such lesions are often heavily calcified or fibrotic and undilatable with the present balloon technology and attempts to treat them with balloon angioplasty or intracoronary stent placement often lead to vessel dissection or incomplete stent deployment with resultant adverse outcomes. Rotational atherectomy remains a useful niche device for the percutaneous treatment of such complex lesions, usually as an adjunct to subsequent balloon angioplasty and/or intracoronary stent placement. In contrast to balloon angioplasty or stent placement that widen the coronary lumen by displacing atherosclerotic plaque, rotational atherectomy removes plaque by ablating the atherosclerotic material, which is dispersed into the distal coronary circulation. Other lesion subtypes amenable to treatment with this modality include ostial and branch‐ostial lesions, chronic total occlusions, and in‐stent restenosis. This review discusses the technique and principles of rotational atherectomy, the various treatment strategies for its use (including adjunctive pharmacotherapy), the lesion‐specific applications for this device, and the complications unique to this modality. Recommendations are also made for its use in the current interventional era. Catheter Cardiovasc Interv 2004;62:485–498. © 2004 Wiley‐Liss, Inc.
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In general, coronary stents, when deployed in a coronary artery by conventional balloon expansion, appear to be tightly forced into the vessel wall, virtually precluding intentional or unintentional removal of the stents. Here, we present a case of unintended coronary stent extraction during cutting balloon angioplasty for high-grade in-stent restenosis of a stent successfully deployed 4 months earlier. The blades of the cutting balloon became stuck in the stent struts. Retrieval of the cutting balloon was only possible in conjunction with the stent using increased traction. Subsequent vessel closure was recanalized and a paclitaxel-eluting stent was implanted, covering the entire region of the previous stent and rendering an excellent angiographic result. Careful inspection of the extracted stent demonstrated complete removal. Retrospective analysis of the stent implantation procedure 4 months prior revealed complete stent expansion and closely matched stent and vessel dimensions as assessed by angiographic criteria.
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The current routine use of intracoronary stents in percutaneous coronary intervention (PCI) has significantly reduced rates of restenosis, compared with balloon angioplasty alone. On the contrary, small post-stenting luminal dimensions due to undilatable, heavily calcified plaques have repeatedly been shown to significantly increase the rates of in-stent restenosis. Rotational atherectomy of lesions is an alternative method to facilitate PCI and prevent underexpansion of stents, when balloon angioplasty fails to successfully dilate a lesion. Stentablation, using rotational atherectomy to expand underexpanded stents deployed in heavily calcified plaques, has also been reported. We report a case via the transradial approach of rotational-atherectomy–facilitated PCI of in-stent restenosis of a severely underexpanded stent due to a heavily calcified plaque. We review the literature and suggest rotational atherectomy may have a role in treating a refractory, severely underexpanded stent caused by a heavily calcified plaque through various proposed mechanisms.
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We report treatment of a lesion with coronary stent underexpansion due to heavily calcified plaque. Conventional balloon angioplasty was attempted for in-stent restenosis, but the lesion was undilatable despite 25-atm inflation pressure. Intravascular ultrasound (IVUS) revealed stent underexpansion due to heavily calcified plaque. Rotational atherectomy was performed using a stepped burr approach, after which repeat IVUS revealed marked ablation of the stent-calcium complex. Adjunctive balloon angioplasty then easily resulted in full balloon and stent expansion, with an excellent angiographic and IVUS result. The patient's hospital course was uneventful. Cathet Cardiovasc Intervent 2001;52:208–211. © 2001 Wiley-Liss, Inc.
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