Angiographic characteristics of femoropopliteal in‐stent restenosis: Association with long‐term outcomes after endovascular intervention

Abstract

Objectives The purpose of this study was to identify the relationship between angiographic patterns of restenosis and outcomes after endovascular treatment of femoro-popliteal in-stent restenosis (FP-ISR). Background ISR is a frequent clinical problem after femoro-popliteal stenting. Methods This was a single center study of all endovascular interventions for FP-ISR from 2006 to 2012. Class I ISR was defined as focal lesions ≤50 mm; Class II ISR as lesions > 50 mm; and Class III ISR as stent chronic total occlusion. Recurrent ISR was defined as peak systolic velocity ratio > 2.4 by duplex ultrasound. Results Among 75 cases of FP-ISR, 28 (37%) were Class I, 22 (29%) were Class II, and 25 (33%) were Class III. The mean lesion length was 26 mm for Class I, 135 mm for Class II, and 178 mm for Class III ISR. Patients with Class III ISR more frequently had ISR extending into both the superficial femoral and popliteal artery (48% vs. 18%, P = 0.005). Balloon angioplasty was used most frequently to treat Class I ISR, while adjunctive atherectomy and/or stenting was used for almost all cases of Class III ISR. During 2-year follow-up, rates of repeat restenosis were 39% for Class I, 67% for Class II, and 72% for Class III ISR (P = 0.04). Rates of stent occlusion were 8% for Class I, 11% for Class II, and 52% for Class III ISR (P = 0.009). Class III ISR was associated with significantly increased risk of recurrent ISR (HR 2.4, 95% CI 1.1–5.6) and recurrent occlusion (HR 5.8, 95% CI 1.8–19.0) compared to other types of ISR. Conclusion Angiographic patterns of FP-ISR are important determinants of subsequent outcomes. Repeat restenosis and occlusion remain common despite currently available technologies.

Recent advances in self-expanding stents for use in the superficial femoral and popliteal arteries

“…Among patients with in-stent restenosis, 108 patients with 119 lesions (mean lesion length 133 mm) were treated with Zilver DES. Primary patency was 78.8% at 1 year, which compares favorably with previously reported outcomes of other treatment modalities for femoropopliteal in-stent restenosis [40,41]. These preliminary results suggest that Zilver DESs may have a significant role in the treatment of lesions that are otherwise at high risk of restenosis with standard therapies.…”

“…Ultimately, direct comparisons of newer technologies will be necessary. Such studies will also have to consider the cost and outcomes of in-stent restenosis that has poor long-term patency and remains difficult to treat despite available technologies [41]. Whether drug-coated balloons will disrupt or diminish the use of nitinol stents also remains an important unanswered question in the optimal treatment of patients with femoropopliteal disease.…”

Laser Atherectomy for Treatment of Femoropopliteal In-Stent Restenosis

“…One recent study showed high rates of restenosis and recurrent occlusion for class II and III FP-ISR even with the use of adjunctive devices and provisional stenting, thus raising concern that currently available technologies may not improve outcomes of FP-ISR compared with balloon angioplasty alone. 28 Given that in-stent occlusion contains both neointima and thrombus, laser atherectomy, by debulking the neointima and thrombus and inhibiting platelet aggregation, offers a potentially promising therapeutic avenue for treatment of FP-ISR. 16 Several studies have examined the use of laser atherectomy for treatment of FP-ISR, but those studies did not specifically analyze the association of angiographic characteristics with outcomes.…”

Drug-Coated Balloons as the New Standard of Care for Femoropopliteal In-Stent Restenosis

“…In a follow-up to that study, we evaluated a multimodality approach to the treatment of FP-ISR. 7 Seventy-five patients underwent endovascular treatment of FP-ISR using a variety of adjunctive devices, including laser atherectomy, excisional atherectomy, and repeat stenting. Despite the use of these adjunctive therapies in the majority of cases, rates of repeat restenosis at 2 years were 39% for class I ISR, 67% for class II ISR, and 72% for class III ISR.…”