Curative treatment of restenosis.

It has been clearly demonstrated that post-angioplasty restenosis is the re sult of the combination of three distinct mechanisms associated to differen t degrees : constrictive remodelling, neo-intimal hyperplasia and elastic r ecoil. In contrast, after stent implantation, constrictive remodelling is n il, elastic recoil is very mild and restenosis, when observed, is essential ly due to a reaction of intimal hyperplasia. These physiopathological featu res are important as they affect the therapeutic opportunities. With rates of stent implantation attaining 100% in some centres, intra-sten t restenosis is a new pathology which poses serious problems in everyday pr actice as the best management of this situation has not yet been determined , For a long time, redilatation with a balloon catheter was the only possib le solution. Secondarily, ablative techniques were evaluated, such as rotational and las er atherectomy, techniques with the theoretic advantage of eliminating part of the intimal proliferation. Directional atherectomy has also been used b y some groups. More recently, other approaches, such as implantation of a s econd stent inside the first, the cutting balloon and radiotherapy, have be en suggested. A surgical option is always possible in cases of repeat and/o r diffuse restenosis. Finally, abstention from any local treatment may be j ustified in asymptomatic patients. These different approaches are discussed in this paper.