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Treatment of drug-eluting stent restenosis
Drug-eluting stent restenosis is becoming an increasingly frequent problem given the large number of patients in whom they have been placed. There have been few reports addressing the management of this problem and no randomized trials have compared treatment options (1-3).In a two-year follow-up of patients enrolled in the SIRIUS trial, 22 of 533 patients (4 percent) had ischemia driven target lesion revascularization with the first year of follow-up (3). Treatment was at the operator's discretion and included bare metal stent implantation, balloon dilatation, or intravascular brachytherapy. At one year follow-up after the first recurrence, five patients (23 percent) required a repeat revascularization procedure. There are limited data regarding the safety and effectiveness of a second DES for DES restenosis(1). In a series of 116 patients with restenosis of either a PES or SES, repeat stenting with a DES was safe but associated with a high rate of target vessel revascularization (29 percent at one year) (4). The rate was similar whether the same or alternative DES was used for the repeat procedure.

More recently, drug-coated balloon was introduced for treatment of in-stent restnosis. Early studies using angioplasty balloons coated with antiproliferative drugs in de novo lesions failed to demonstrate efficacy for the prevention of intracoronary restenosis. However, this technique may have application for the treatment of in-stent restenosis. In an early study, paclitaxel-coated balloons significantly reduced in-segment late luminal loss compared to uncoated balloons when used in patients with in-stent restenosis (5). The results were better than those obtained using first generation drug-eluting stents (6). In a more recent study, 131 patients with in-stent (BMS) restenosis were randomly assigned to either a paclitaxel-coated balloon or a paclitaxel-eluting stent (PES) (7). At six months, the paclitaxel-coated balloon significantly reduced the primary end point of in-segment late lumen loss compared with the PES (0.17 versus 0.38 mm respectively). At 12 months there was a non-significant trend toward a lower rate of major adverse cardiac events (target lesion revascularization, stent thrombosis, myocardial infarction, and death) with the coated-balloon (9 and 22 percent). This difference seen was attributable principally to a lower rate of target lesion revascularization with the coated balloon (6 versus 15 percent).

In summary, there is insufficient evidence at this time to recommend any specific treatment for DES restenosis. Repeat stenting with a DES is currently performed in many institutions. Such patients should be evaluated by IVUS and stent expansion optimized by repeat balloon angioplasty.
REFERENCES
1. Mishkel, GJ, Moore, Al, Markwell, S, et al. Long-term outcomes after management of restenosis or thrombosis of drug-eluting stents. J Am Coll Cardiol 2007; 49:181.
2. Lemos, PA, van Mieghem, CA, Arampatzis, CA, et al. Post-sirolimus-eluting stent restenosis treated with repeat percutaneous intervention: late angiographic and clinical outcomes. Circulation 2004;109:2500.
3. Moussa, ID, Moses, JW, Kuntz, RE, et al. The fate of patients with clinical recurrence after sirolimus-eluting stent implantation ( a two-year follow-up analysis from the SIRUS trial). Am J Cardiol 2006;97:1582.
4. Garg, S, Smith, K, Torguson, R, et al. Treatment of drug-eluting stent restenosis with the same versus different drug-eluting stent. Catheter Cardiovasc Interv 2007; 70:9.
5. Scheller, B, Hehrlein, C, Bocksch, W, et al. Treatment of coronary in-stent restenosis with a paclitaxel-coated stent for the treatment of coronary in-sttent restenosis. Circulation 2009; 119:2986.
6. Stone, GW, Ellis, SG, O’Shaughnessy, CD, et al. Paclitaxel-eluting stents vs vascular brachytherapy for in-stent restenosis within bare-metal stents: the TAXUS V ISR randomized trial. JAMA 2006; 295: 1253.
7. Unverdorben, M, Vallbracht, C, Cremers, B, et al. Paclitaxel-coated balloon catheter versus paclitaxel-coated stent for the treatment of coronary in-stent restenosis. Circulation 2009: 119:2986.

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