CORONARY ARTERY RESTENOSIS: CAUSES, TREATMENT AND CLINICAL OUTCOMES

CORONARY ARTERY RESTENOSIS: CAUSES, TREATMENT AND CLINICAL OUTCOMES

Library of Congress Cataloging-in-Publication Data

Contents

Preface

Part I. Definition, Pathophysiology, and Diagnosis

Chapter 1: Restenosis: Historical Background and Incidence

Abstract

Introduction

Definitions

Diameter Stenosis (The Emory Definition)

Late Loss

Loss Index

Rotterdam Definition

Minimum Luminal Area

National Heart Lung and Blood Institute Definition

Mechanism of Restenosis

Clinical Sequelae

Risk Factors for Restenosis

Conclusion

References

Chapter 2: Mechanisms of Restenosis

Abstract

Introduction

Coronary Artery Anatomy

Risk Factors

Balloon Angioplasty Restenosis

Elastic Recoil

Positive and Negative Remodeling

Bare Metal Stent Restenosis

Neointimal Hyperplasia

Drug-Eluting Stent Restenosis

Neoatherosclerosis

Conclusion

Future Directions

References

Chapter 3: Morphologic Patterns of In-Stent Restenosis

Abstract

1. Introduction

2. Classification of Angiographic Patterns of In-Stent Restenosis

3. Impact of ISR Pattern on Clinical Outcomes

4. Histopathology of ISR

5. Patterns of ISR in BMS and DES

5.1. Comparison between BMS and 1st generation DES

5.2. ISR Morphology in 1st Generation DES

5.3. ISR Morphology in 2nd Generation DES

6. Edge Vascular Response and In-Stent Restenosis

7. ISR Morphology in Patients with Diabetes Mellitus

8. Endovascular Imaging and ISR

8.1. IVUS Assessment of ISR

8.2. OCT Assessment of ISR

10. Fractional Flow Reserve and ISR Morphology

11. Patterns of ISR: Therapeutic Implications

Conclusion

References

Chapter 4: Coronary Restenosis: Clinical Outcomes

Abstract

Introduction

Definition

Clinical Presentation

Angiographic Patterns of Restenosis and Implications for Clinical Outcomes

Restenosis in Major DES Trials

Conclusion

References

Chapter 5: Late Phase In-Stent Restenosis after Coronary Stent Implantation

Abstract

Introduction

Clinical Course of ISR after BMS Implantation

Late In-Stent Restenosis after BMS Implantation

Late In-Stent Restenosis after DES Implantation

In-Stent Restenosis and Inflammation

Pathological Mechanism of Neoatherosclerosis in Stents

Difference in Neoatherosclerosis between BMS and DES

Optical Coherence Tomography and Plaque Characteristics in ISR

Intracoronary Imaging of Late Phase ISR after BMS Implantation

Intracoronary Imaging of Late Phase ISR after DES Implantation

Relationships between ISR, Neoatherosclerosis, and Stent Thrombosis

Prevention of Very Late ISR

Interventional Strategy for Very Late ISR

Conclusion

References

Chapter 6: Stent Sizing Without Intravascular Imaging: Impact on Restenosis

Abstract

Introduction

Lessons in Balloon Sizing from the Balloon Angioplasty Era

Lessons on Stent Sizing and Drivers of Restenosis from Intravascular Ultrasound Trials

Concerns with Stent Over-Expansion

Reliability of Manufacturers’ Balloon Compliance Charts

Sizing Stents Without IVUS

Aggressive Stent Expansion without Intravascular Imaging: Incidence and Impact on Restenosis

Conclusion

References

Part II. Diagnosis of Restenosis Using Fractional Flow Reserve, Intravascular Ultrasound, Optical Coherence Tomography, and Coronary Computed Tomography Angiography

Chapter 7: Physiological Assessment of Coronary Restenosis

Abstract

Introduction

Physiological Consequences of An epicardial Stenosis

Fractional Flow Reserve as the Most Widely Used Index to Assess the Ischemic Potential of an Epicardial Stenosis

Functional Treatment of Coronary Restenosis

Can Physiology Help Identify Patients prone to Develop Post-Intervention Adverse events?

Conclusion

References

Chapter 8: The Role of Intravascular Ultrasound in Understanding the Mechanism, Prevention and Management of Restenosis

Abstract

Introduction

Role of IVUS in Understanding the Mechanism of Restenosis

Neo Intimal Hyperplasia

Mechanical Factors

Stent Under Expansion

Stent Malapposition

Stent Fracture

Stent Edge Restenosis

Role of IVUS in Prevention of Restenosis

Role of IVUS for Prevention of Restenosis in Bare Metal Stents

Role of IVUS in Preventing Restenosis in Drug Eluting Stent Era

IVUS Predictors of in Stent Restenosis

IVUS Criteria for Optimal Stent Deployment

Role of IVUS in Treatment of in Stent Restenosis

Balloon / Cutting Balloon Angioplasty

Brachytherapy

Repeat Stenting with DES

Conclusion

References

Chapter 9: Optical Coherence Tomography: Current Utility and Future Potential for Management of In-Stent Restenosis

Abstract

Introduction

Technical Characteristics of OCT

Mechanism of ISR and Its Relevance to OCT

The Patterns of In-Stent Restenosis Using OCT

OCT Use in the Evaluation of ISR in Bare Metal Stents

OCT Use in the Evaluation of ISR of Drug-Eluting Stents

OCT Findings in DES versus BMS In-Stent Restenosis

Comparison of OCT with Other Technologies

OCT versus IVUS in In-Stent Restenosis

OCT versus FFR in In-Stent Restenosis

Applications of OCT to Decrease the Incidence of In-stent Restenosis

Determination of Adequacy of PCI

Selection of Type of Treatment

Assessment of Vulnerability of Plaque

Reduction in Target-vessel Revascularization

Tissue Coverage of Stent Struts

Future Applications of OCT

Limitations

Conclusion

References

Chapter 10: Coronary CTA for the Evaluation of In-Stent Restenosis

Abstract

Introduction

Coronary Computed Tomography

Technical Considerations

Appropriateness of CT for Evaluation

of Stents and Assessment of ISR

Artifacts in Coronary Stent Evaluation

Recent Advances in CT Techniques

Clinical Utilization and Literature Review

in Evaluation of In-Stent Restenosis

Physiological Assessment of In-Stent

Restenosis: Myocardial Perfusion, CT-FFR

and Myocardial Tagging Techniques

Emerging Utilization for Newer Generation Stents

Limitations of CT in Evaluating In-Stent Restenosis

Conclusion

References

Part III. Treatment of Restenosis

Chapter 11: Pharmacotherapy of Coronary In-Stent Restenosis

Abstract

Introduction

A. Possibly Effective

1. Colchicine

2. Cilostazol

3. Thiazolidinedione

4. Oral Sirolimus

5. Calcium Channel Blockers

6. Corticosteroids

7. Probucol

8. Celecoxib

B. Probably ineffective

1. Statins (HMG-CoA Reductase Inhibitors)

2. Tranilast

3. Angiotensin-Converting Enzyme (ACE) Inhibitors

4. Homocysteine Lowering Agents and Folate Therapy

5. Fish Oil

6. Carvedilol

7. Triazolopyrimidine (Trapidil)

8. Somatostatin Analogues

C. On the Horizon

1. Nanotechnology

2. Gene Therapy

Conculsion

References

Chapter 12: Interventional Treatment of Restenosis

Abstract

Introduction

Review of the Mechanisms of Restenosis

Patterns of Restenosis

Approaches to ISR

Repeat Balloon Intervention

Bare Metal Stenting

Athroablation

Vascular Brachytherapy

Drug Eluting Stents

Drug Eluting Balloons

Conclusion

References

Chapter 13: Saphenous Vein Graft Restenosis and Management

Abstract

Background

Pathogenesis of Vein Graft Disease

Response of SVG Intima after Stent Implantation

SVG Stenosis and Occlusion

Clinical Presentation

Management of SVG Stenosis

Diagnostic Modalities for SVG Stenosis

IVUS-Guided PCI for SVG Stenosis

PCI versus Redo-CABG

Initial Experience of PTCA for SVG Stenosis

PTCA versus BMS Stent for SVG Stenosis

Covered Stents and SVG PCI

Radiotherapy for SVG PCI

Gamma-Radiation versus Beta-Radiation

DES and SVG Intervention

Optimization of Management of SVG Disease

1. Pharmacological Management

2. Intervention Techniques

Native Coronary Vessel PCI instead of SVG PCI

Gene Therapy

Conclusion

References

Part IV: Future Strategies in the Treatment of Restenosis

Chapter 14: Prevention of Restenosis with Stent-Based Vascular Gene Delivery: Gene Eluting Stents

1Children’s Hospital of Philadelphia

2University of Pennsylvania, PA, US

Abstract

Introduction: The Problem of In-Stent Restenosis in the Era of Drug Eluting Stents

The Concept of Gene Eluting Stents (GES)

GES Prototypes

Bulk Immobilization

Surface Immobilization of Gene Vectors on Coatless Metal Substrate

Vector immobilization via affinity adaptors

Vector immobilization via hydrolyzable cross-linkers

Magnetic Targeting of Gene Vectors to Magnetizable Stents

Magnetic Reloading of Depleted GES

Reporter Studies and Pharmacokinetics of

Transgene Expression

Molecular Targets for the Prevention of Restenosis and Therapeutic Transgenes

GES Targeting Endothelial Re-Growth

GES Targeting SMC Proliferation, Migration and ECM Remodeling

GES Targeting Stenting-Induced Inflammation

GES Targeting Thrombus Formation in Stented Arteries

GES Targeting Nitric Oxide Production and Availability

Conclusion

Acknowledgments

References

Chapter 15: Future Strategies for Preventing and Treating Coronary Restenosis

Abstract

I. Introduction

II. Prevention of Restenosis

a. Stent Platform

i. New Alloys

ii. Bioresorbable Scaffolds

b. Drug Elution Polymer and Stent Coatings

i. Biocompatible and Bioabsorbable Polymers

ii. Polymer-Free Drug Elution

iii. Nanoparticles

iv. Novel Coating Agents

c. Local Antirestenotic Agents

d. Gene Therapy

e. Agents to Promote Endothelial Cell Healing

f. Systemic Treatment

III. Treatment of Restenosis

a. Drug-Eluting Stents

b. Drug Coated Balloons

c. Brachytherapy

d. Maximizing Luminal Gain and Stent Expansion

i. Rotational Atherectomy

ii. Laser Atherectomy

Conclusion

References

Editor Contact Information

Index