BALLOON ANGIOPLASTY OF IN-STENT-RESTENOSIS - EARLY AND LATE RESULTS OF THE FIRST AND 2ND DILATATION IN FOCAL AND DIFFUSE STENOSIS

From January 1996 untill February 1997 6,376 patients were treated by our group with PTCA and 3,859 (60.5 %) received one or several stents. An angiographic followup was achieved in 63 % of the patients with 1, 267 experiencing restenosis (32.8 %). Of those beeing treated with re- PTCA 302 were randomly selected for further analysis. In-stent-resteno sis was treated with rotablator in 8 patients (2.7 %), with eximer las er in 21 (7.0 %) and with another stent in 48 patients (15.9 %). 225 p atients (74.4 %) of this subselection were treated with balloon-angiop lasty only. Mean patient age was 63 +/- 10.2 years, 401 stents had bee n implanted (42.5 % Wiktor, 13.7 % Jomed Site, 12.3 % ACS Multilink, 9 .5 % GR II, and some others), the number of stents per patient was 1.6 8, mean stent length 28.5 mm, mean stent diameter 3.01 +/- 0.3 mm, the time since implantation 142 +/- 76 days. The recurrence appeared as r estenosis in 199 patients (88.4 %) and as a chronic stent occlusion in 26 (11.6 %). In-stent-restenosis was discovered in 94.7 % within the stent and was of focal appearance (restenosic lesion of less than or e qual to 5 mm) in 28.5 % and diffuse (> 5 mm) in 71.5 %. Balloondilatat ion (balloon : artery = 1:1;maximal pressure 11.7 +/- 3.3 bar) was suc cessfull in 98 % of the stenotic lesions and in 18/26 of the chronical ly occluded stents (definition of success: residual stenosis < 50 %, n o major complications). The stenosis decreased from 82.2 % to 20.5 % ( 12.8 % in focally stenosed vessels and 23.6 % in diffuse restenosis). Complications were death in 0.9 %, Q-MI in 0 % CABG in 0.9 %, Non-Q-Ml in 2.4 %, subacute stent thrombosis in 0.5 % and groin bleeding in 1. 8 %. A clinical follow up after 151.7 +/- 87.7 days was achieved in 98 .6 % and an angiographic follow up in 69.1 % of the patients: 1.9 % ha d died (2/4 due to noncardiac disease), no Ml, 6.2 % CABG and 31 % PTC A (TLR 37.2 %). A second restenosis within the stents ocurred in 27.9 % of those with focal disease and in 44.3 % of those with diffuse in s tent restenosis. Conclusions: Restenosis within stents may occurr in a bout 30 % of unselected patients. In 2/3 these stenoses appear diffuse and in 10 % they appear as chronic occlusions. Re-PTCA with balloons is rather simple with a high success rate (even in chronic stent occlu sions) and a low complication rate. The incidence of a second restenos is is acceptably high in focal lesions but appears unacceptable in pat ients with diffuse in-stent-restenosis. Thus the indication for stenti ng should be restricted to patients with clear cut advantage over ball oon-angioplasty alone, e.g. threatening closure, chronic occlusion, ol d savenous veingraft and proximal LAD stenosis.