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In-Stent Restenosis Trends in US Practice
Quick Takes
- In-stent restenosis (ISR) represents 10% of all PCIs in contemporary practice with stable trends from 2009-2017.
- 25% of patients with ISR present with acute events.
- The mainstay of ISR treatment is repeat DES implantation.
Study Questions:
What are temporal trends in clinical presentation, treatment strategies, and in-hospital outcomes among patients undergoing percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) in the United States?
Methods:
Data were collected from the Diagnostic Catheterization and Percutaneous Coronary Intervention (CathPCI) registry of the National Cardiovascular Data Registry (NCDR) between 2009 and 2017. All patients undergoing PCI for ISR lesions were identified. For comparison of in-hospital outcomes, propensity-score matching was used.
Results:
Among the 5,100,394 patients undergoing PCI, 10.6% of patients underwent PCI for ISR lesions. Patients with bare-metal stent ISR declined from 2.6% in 2009 Q3 to 0.9% in 2017 Q2 (p < 0.001), and drug-eluting stent (DES) ISR rose from 5.4% in 2009 Q3 to 6.3% in 2017 Q2 (p < 0.001). Patients with ISR PCI were less likely to present with non–ST-segment elevation myocardial infarction (NSTEMI) (18.7% vs. 22.5%; p < 0.001) or STEMI (8.5% vs. 15.7%; p < 0.001). In the propensity-matched population of patients, there were no significant differences between patients with ISR and non-ISR PCI for in-hospital complications and hospital length of stay.
Conclusions:
ISR represents approximately 10% of all PCIs and is treated most commonly with another stent. Approximately 25% of patients present with acute MI. In-hospital outcomes of patients with ISR PCI are comparable with those undergoing non-ISR PCI.
Perspective:
ISR continues to be the achilles’ heel of PCI. This robust analysis from the NCDR suggests that ISR remains prevalent (10% of all PCIs) and stable in occurrence in contemporary practice despite advancements in stent technology. Although patients with ISR lesions are less likely to present with acute coronary syndrome compared to de novo disease, about 25% of all ISR lesions do present acutely. Optimal management of ISR remains debated and the role of drug-coated balloons remains to be determined. Optimizing initial stent implantation and aggressive modification of patient-related risk factors known to increase ISR should be prioritized while we await advancement in stent and balloon technology geared towards reducing stent failure.
Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Vascular Medicine, Interventions and ACS, Interventions and Vascular Medicine, Chronic Angina
Keywords: Acute Coronary Syndrome, Catheterization, CathPCI Registry, Coronary Restenosis, Drug-Eluting Stents, Myocardial Infarction, National Cardiovascular Data Registries, Percutaneous Coronary Intervention, ST Elevation Myocardial Infarction, Stents
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