Tuesday, March 21, 2006

In-stent restenosis - the best treatment, by far

Insertion of stents that release the drug paclitaxel to treat stenosis within an implanted bare-metal stent in a coronary artery (in-stent restenosis or ISR) reduces the risk of subsequent re-narrowing within the stent, when compared with treatment using intra-coronary radiation (VBT), according to a new study.

"Although the initial success rate is high following repeat percutaneous coronary intervention for in-stent restenosis lesions, subsequent recurrence rates are further increased and refractory restenosis remains the single most common reason for referral to coronary artery bypass graft surgery after bare-metal stent implantation," the trial authors noted. "Identification of the optimal therapy for bare-metal in-stent restenosis carries significant public health implications."
  • We know that restenosis occurs in 10% to 50% or more of patients following implantation of the old bare-metal stents.
  • Drug-eluting (releasing) stents have been demonstrated to safely reduce restenosis compared with bare-metal stents.

Results of the study:

Paclitaxel-eluting stents reduced the 9-month composite rate of major adverse cardiac events by 43% compared with VBT. Patients with paclitaxel-eluting stents had a 53% lower rate of angiographic restenosis at 9 months, compared with VBT.

"The results from this trial in concert with other studies, indicate that drug-eluting stents should now be considered the treatment of choice for most patients with ISR of previously implanted bare-metal stents.

(Head-to-head trials of drug-eluting stent–in–drug-eluting stent -with the same vs. a different antiproliferative agent-will be needed.)

Looks like they just put the nail in the coffin for brachytherapy treatment for restenosis. ISR, the gold-standard for treatment of in-stent restenosis, popular in the late 1990s, may now have to bow out. But, it should be noted:

"There may remain a small fraction of patients with in-stent restenosis who will be better served with brachytherapy. These would include patients with bifurcation restenotic lesions; vessels or lesions with excessive calcification, tortuosity, or angulation; and other scenarios that may make repeat stenting unsuitable or lead to an increased risk of procedure-related ischemic events. In other words, vessels hard to reach or those with hardened, calcified plaque.

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