Restenosis and PercutaneousOptions Flashcards
What are the clinical and anatomical predictors of restenosis following BMS placement?
- Diabetes mellitus
- Ostial or SVG lesion location
- Prior restenosis
- Smaller reference vessel diameter
- Smaller postintervention minimum luminal diameter
- Longer lesions
- Greater total stent length
These variables also serve as risk factors for restenosis after DES implantation.
What were the findings of the EVOLVE II trial regarding bioabsorbable polymer-coated everolimus-eluting coronary stents versus durable polymer-coated everolimus stents?
No significant differences in TVR or stent thrombosis rates between the stents
Kereiakes DJ, et al. Circ Cardiovasc Interv 2015;8(4):e002372.
How does restenosis within BMS compare to restenosis within DES in terms of timing and characteristics?
- Restenosis within BMS presents significantly later after stent implantation
- Associated with greater volumes of neointimal hyperplasia
- Shorter lesion lengths compared to restenosis within DES
Goto K, et al. Am J Cardiol 2015;116(9):1351–1357.
What role does inflammation play in the pathogenesis of coronary restenosis?
Inflammation promotes proliferation and migration of vascular smooth muscle cells and fibroblasts, leading to neointimal tissue development
Costa MA, et al. Circulation 2005;111(17): 2257–2273.
What are the key differences between restenotic lesions and atherosclerotic plaques?
- Restenotic lesions exhibit more homogenous fibrohyperplastic morphology
- Atherosclerotic plaques typically show complex features such as lipid pools, necrotic cores, fibrous caps, and focal calcification
Acute plaque rupture with thrombotic vessel occlusion is less common in restenosis.
What factors influence the effectiveness of animal models in studying restenosis?
- Histologic appearance and composition differences
- Metabolic, physiologic, and hemodynamic differences
- No single model replicates all features of human restenosis
Various animal models like mice, pigs, and dogs show variability in neointimal formation.
What were the findings of the ISAR DESIRE-3 trial regarding PEB angioplasty and PES placement?
- PEB: 27% angiographic restenosis
- PES: 24% angiographic restenosis
- Balloon angioplasty: 57% angiographic restenosis
Byrne RA, et al. Lancet 2013;381(9865):461–467.
Define late loss in the context of percutaneous coronary intervention (PCI).
Late loss is the in-stent minimum lumen diameter immediately following stent placement minus the in-stent minimum lumen diameter on late follow-up angiography
Example: Late loss = 3.40 − 2.98 = 0.42 mm.
What is the late loss index and how is it calculated?
Late loss index = late loss / acute gain
This normalizes late loss for acute gain achieved during the procedure.
True or False: Stent implantation leads to a reduced frequency of restenosis compared to balloon angioplasty.
True
Stent placement eliminates long-term negative remodeling of the vessel wall.
What is neoatherosclerosis and how does it differ from in-stent restenosis?
- Neoatherosclerosis has pathologic features similar to de novo atherosclerosis
- More prone to plaque rupture and clinical presentation with acute coronary syndrome
Finn AV, et al. Circ Cardiovasc Interv 2012;5(1):6–9.
What is the common timing for in-stent restenosis following BMS implantation?
Typically occurs within the first 6 months following stent implantation
After 6 months, spontaneous regression in luminal narrowing may occur (Kimura T, et al. N Engl J Med 1996;334(9):561–566).
What strategies should be considered for symptomatic in-stent restenosis?
- Repeat PCI
- Medical therapy
- CABG
Treatment should be based on patient and lesion-specific factors.
What are microtubules and their role in cellular functions?
Microtubules are essential for the mitotic spindle apparatus, cellular migration, and growth factor signaling
Paclitaxel stabilizes microtubules, interrupting cellular division.
What were the outcomes of randomized trials comparing PES and EES placement?
Higher rates of late loss and/or target vessel failure were observed with PES compared to EES
SPIRIT III, SPIRIT IV, and COMPARE trials.
What is associated with a decreased incidence of major adverse cardiac events (MACE) among patients presenting with ACS?
Routine early invasive strategy
A conservative approach is not preferred for treatment in these cases.
Which trial indicates that bypass surgery is associated with reduced rates of death and myocardial infarction (MI) in patients with diabetes and multivessel disease?
FREEDOM trial
This trial highlights the advantages of bypass surgery over drug-eluting stents (DES) in specific patient populations.
What are the patterns of in-stent restenosis identified by Mehran et al.?
The patterns are:
* Focal
* Total occlusion
* Diffuse proliferative
* Diffuse intrastent
These classifications are based on the likelihood of late patency following repeat intervention.
Which pattern of in-stent restenosis is associated with the lowest need for repeat revascularization?
Focal pattern
This is followed by diffuse intrastent, diffuse proliferative, and total occlusion patterns.
True or False: Histologically, DES restenosis typically shows more homogenous hypercellular neointima than BMS restenosis.
False
DES restenosis is more likely to show organized thrombus and fibrin deposition.
What biological factor appears predictive of BMS restenosis but not DES restenosis?
Serum markers of inflammation, most notably CRP
Elevated serum CRP levels are associated with a predisposition to restenosis in BMS, but not in DES.
Fill in the blank: The tendency toward thrombus deposition within DES reflects the lack of protective _______.
neointima
This contrasts with the situation following BMS placement.
What is associated with reduced measures of restenosis following both BMS and DES placement?
IVUS guidance
A meta-analysis supports the effectiveness of IVUS in optimizing stent sizing.
What has randomized trials shown regarding stents with thinner struts?
They are associated with a significant reduction of angiographic and clinical restenosis
This finding emphasizes the importance of stent design in preventing restenosis.
What is the preferred treatment choice for carotid in-stent restenosis?
Uncertain
Although repeat angioplasty or stenting is often performed, clinical outcomes compared to medical therapy are unclear.
What clinical risk factors are associated with in-stent restenosis following BMS placement?
Risk factors include:
* SVG location
* Ostial lesion location
* Female gender
* Nonsmoking status
* Diabetes mellitus
* ACS
* Lesion length >20 mm
* Smaller vessel diameter
* Prior PCI
* Multiple stents
* ACC/AHA type C lesion classification
These factors can help in assessing the risk for restenosis.
What does Sirolimus inhibit in the body?
The mechanistic target of rapamycin (mTOR) protein
Sirolimus is known for its role in preventing restenosis through its effects on vascular smooth muscle cell proliferation.
What is the incidence of late stent fracture according to recent meta-analysis?
Mean incidence is 4.0%
The range among studies is from 0.8% to 8.4%.
What are the complications associated with stent fracture?
Increased incidences of:
* Angiographic in-stent restenosis
* Target lesion revascularization
* Definite stent thrombosis
Fractures are more common in the RCA than in other arteries.
What is the procedure of choice for recoarctation treatment?
Catheter-based therapy (angioplasty or stenting)
This approach should be individualized and directed by a heart team.
True or False: Balloon valvotomy is contraindicated for the treatment of subvalvular or supervalvular aortic stenosis.
True
This procedure is more suitable for children and young adults with severe noncalcific congenital aortic stenosis.
When is coarctation repair indicated?
Coarctation repair is indicated for symptomatic or asymptomatic individuals when the peak instantaneous pressure gradient is ≥20 mm Hg, or if collateral vessels are detected.
Reference: Warnes CA, et al. Circulation 2008, 118(23):e714–e833.
What is the current procedure of choice for recoarctation treatment?
Catheter-based therapy (angioplasty or stenting) is the procedure of choice for the treatment of recoarctation.
Treatment should be individualized and directed by a heart team approach.
Is recoarctation more common in children or adults?
Recoarctation is more common among children than adults following balloon angioplasty.
What did a randomized trial compare regarding coarctation lesions?
A randomized trial compared covered and bare stents in 120 adolescent and adult patients with discrete coarctation lesions.
What were the results of the randomized trial on stents for coarctation lesions?
The trial reported no differences in the incidence of recoarctation or pseudoaneurysm at follow-up.
