Percutaneous and surgical interventions for in-stent restenosis: Long-termoutcomes and effect of diabetes mellitus

OBJECTIVE We examined long-term outcomes of patients with in-stent restenos is (ISR) who underwent different percutaneous interventions at the discreti on of individual operators: balloon angioplasty (BA), repeat stent or rotat ional atherectomy (RA). We also examined long-term outcomes of patients wit h ISR who underwent coronary artery bypass surgery (CABG). BACKGROUND In-stent restenosis remains a challenging problem, and its optim al management is still unknown. METHODS Symptomatic patients (n = 510) with ISR were identified using cardi ac catheterization laboratory data. Management for ISR included BA (169 pat ients), repeat stenting (117 patients), RA. (107 patients) or CABG (117 pat ients). Clinical outcome events of interest included death, myocardial infa rction, target vessel revascularization (TVR) and a combined end point of t hese major adverse cardiovascular events (MACE). Mean follow-up was 19 +/- 12 months (range = 6 to 61 months). RESULTS Patients with ISR treated with repeat stent had significantly large r average post-procedure minimal lumen diameter compared with BA or RA. (3. 3 +/- 0.4 mm vs. 3.0 +/- 0.4 vs. 2.9 0.5, respectively, p < 0.05). Incidenc e of TVR and MACE were similar in the BA, stent and RA groups (39%, 40%, 33 % for TVR and 43%, 40%, 33% for MACE, p = NS). Patients with diabetes who u nderwent RA had similar outcomes as patients without diabetes, while patien ts with diabetes who underwent BA or stent had worse outcomes than patients without diabetes. Patients who underwent CABG for ISR, mainly because of t he presence of multivessel disease, had significantly better outcomes than any percutaneous treatment (8% for TVR and 23% for MACE). CONCLUSIONS In this large cohort of patients with ISR and in the subset of patients without diabetes, long-term outcomes were similar in the BA, repea t stent and EW groups. Tissue debulking with RA yielded better results only in diabetic patients. Bypass surgery for patients with multivessel disease and ISR provided the best outcomes. (J Am Coll Cardiol 2001;37: 1877-82) ( C) 2001 by the American College of Cardiology.