P1665Outcomes and risk factors for recurrent restenosis in patients treated for coronary in-stent restenosis

Abstract

Introduction: Despite advances in percutaneous coronary intervention (PCI) and coronary artery stent design respectively, in-stent restenosis (ISR) remains a relatively common long-term complication of PCI with a reported incidence of 3-20%. The outcomes of patients treated for restenosis are not currently well clarified with evidence lacking regarding consensus in management of ISR cases. Study aim: To assess trends, management and outcomes, of patients treated for ISR. Methods and Results: This was a cohort study based on this institution's PCI registry. 1012 patients who had PCI for ISR between January 2010 and January 2017 were included in the analysis. Patients with stable angina or acute coronary syndromes (excluding cardiogenic shock) were included. The primary end-points were recurrent restenosis (R-ISR) and MACE (target vessel revascularisation, myocardial infarction and all-cause mortality) recorded at a median follow up of 24 months. 1012 patients were treated for ISR during the time period with a trend to increased rates over time (p=0.02). 419 (41.4%) were treated for stable angina with 593 (58.6%) presenting acutely. 72% of patients were treated with drug-eluting stents (DES) with 28% undergoing treatment with drug-eluting balloon (DEB); with an increased trend for DEB over time. During follow-up, 31.8% had recurrent angiographically confirmed R-ISR with 176 (18.5%) having repeat PCI, 60 (6.3%) undergoing coronary artery bypass grafting (CABG), and 66 (6.9%) managed medically (due to failed PCI, patient preference or CTO). MACE events occurred in 29.7% of patients during follow-up (6.4% mortality, 23.3% TVR/MI). As expected patients with R-ISR had higher event rates during follow-up compared to those without R-ISR (P<0.0001). On multivariate analysis the following independent predictors of recurrent ISR were identified: smaller vessel size (OR 1.49, 95% CI 1.22 to 1.88), total stented length (OR 1.47, 95% CI 1.31 to 1.73, for each 10 mm increase), complex lesion morphology (OR 1.55, 95% 1.21 to 2.21), presence of diabetes mellitus (OR 1.32, 95% 1.19 to 1.46), and history of chronic kidney disease (OR 1.39, 95% CI 1.10 to 1.78). Conclusion(s): Management of patients with ISR remains a persistent problem, particularly for those presenting with DES-ISR. This study shows that despite current treatments, R-ISR is still a challenge with a new focus on optimising procedural factors or new treatment options needed to solve this issue.