Implantation of a Drug-Eluting Stent With a Different Drug (Switch Strategy) in Patients With Drug-Eluting Stent Restenosis: Results From a Prospective Multicenter Study (RIBS III [Restenosis Intra-Stent: Balloon Angioplasty Versus Drug-Eluting Stent])

Study Questions:

What is the effectiveness of a strategy of using drug-eluting stents (DES) with a different drug (switch) in patients with DES in-stent restenosis (ISR)?

Methods:

The RIBS-III (Restenosis Intra-Stent: Balloon Angioplasty Versus Drug-Eluting Stent) study was a prospective, multicenter study that aimed to assess results of coronary interventions in patients with DES ISR. The use of a different DES was the recommended strategy. The main angiographic endpoint was minimal lumen diameter at 9-month follow-up. The main clinical outcome measure was a composite of cardiac death, myocardial infarction, and target lesion revascularization.

Results:

This study included 363 consecutive patients with DES ISR from 12 Spanish sites. The different-DES strategy was used in 274 patients (75%), and alternative therapeutic modalities (no switch) in 89 patients (25%). Baseline characteristics were similar in the two groups, although lesion length was longer in the switch group. At late angiographic follow-up (77% of eligible patients, median 278 days), minimal lumen diameter was larger (1.86 ± 0.7 vs. 1.40 ± 0.8 mm, p = 0.003) and recurrent restenosis rate was lower (22% vs. 40%, p = 0.008) in the different-DES group. At the last clinical follow-up (99% of patients, median 771 days), the combined clinical endpoint occurred less frequently (23% vs. 35%, p = 0.039) in the different-DES group. After adjustment using propensity score analyses, restenosis rate (relative risk, 0.41; 95% confidence interval [CI], 0.21-0.80; p = 0.01), minimal lumen diameter (difference, 0.41 mm; 95% CI, 0.19-0.62; p = 0.001), and the event-free survival (hazard ratio, 0.56; 95% CI, 0.33-0.96; p = 0.038) remained significantly improved in the switch group.

Conclusions:

The authors concluded that in patients with DES ISR, the implantation of a different DES provides superior late clinical and angiographic results than do alternative interventional modalities.

Perspective:

This study suggests that patients with DES ISR, treated with implantation of a different DES, obtain superior clinical and angiographic long-term results compared with those seen with alternative interventions. In particular, the switch strategy achieved a remarkable improvement in all late angiographic parameters, including minimal lumen diameter, percentage of diameter stenosis, late loss, net gain, and recurrent restenosis rate. Given the observational nature of this analysis, adequately powered randomized trials comparing the efficacy of potent second-generation DES, drug-eluting balloons, bioresorbable drug-eluting scaffolds, and conventional balloon angioplasty are indicated to establish optimal therapy for DES-ISR.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Chronic Angina

Keywords: Myocardial Infarction, Propensity Score, Coronary Restenosis, Drug-Eluting Stents, Spain


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