Bare metal stent implantation for in-stent restenosis with a drug-eluting stent

Abstract

Following the positioning of a bare metal stent (BMS) implant, a yellow plaque is healed with a reduction of the color grade and thrombogenicity, i.e. vulnerability by angioscopy in the chronic phase ("plaque sealing" of BMS; the "whitening effect" of BMS). However, we have reported that thrombus and yellow plaque increases at the drug-eluting stent (DES) site. A 71-year-old man underwent percutaneous coronary intervention using two DESs for a severe stenotic lesion in his right coronary artery. Follow-up coronary angiography (CAG) showed in-stent restenosis (ISR) at the stent-overlap site. We performed traditional balloon angioplasty, but follow-up CAG showed ISR again at the same position as the first restenosis. In angioscopic findings, the normal vessel wall was white, but the site of DES implantation was yellow and a yellow, soft, swelling neointimal proliferation-like vulnerable plaque was observed at the restenotic site. In expectation of the "whitening effect" of BMS, we implanted a new BMS. As anticipated, follow-up CAG showed no restenosis. Moreover, the angioscopic findings indicated a clean, white, neointimal proliferation-like stable plaque at the BMS implant site in the yellow vulnerable area of DES. The "BMS in DES" therapy should be considered one of the strategies for ISR of DES.

Differences in clinical and angiographic outcomes with different drug-eluting stents in Japanese patients with and without diabetes mellitus

“…The hyperglycemic state itself is of crucial importance for the excessive risk of diabetic patients with an enhanced thrombotic milieu or endothelial dysfunction by increasing oxidative stress [32]. DES has a greater beneficial effect compared to a bare metal stent or balloon angioplasty [2,5,33] in terms of reducing clinical events in patients with DM, but DES could not show such a beneficial effect comparing patients with and without DM.…”

“…Percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM) is associated with an increased risk of adverse clinical outcomes compared with those without DM [1][2][3]. Recent data have demonstrated that drug-eluting stents (DES) reduce the incidence of restenosis and the need for repeated revascularization compared with bare-metal stents in patients with DM [4,5]. Furthermore, sirolimus-eluting stents [6] (SES) and paclitaxel-eluting stents [7] (PES) dramatically reduce angiographic measures and clinical events compared with bare metal stents in patients with and without DM.…”

Recurrence of angina pectoris after percutaneous coronary intervention is reduced by statins in Japanese patients

“…With the introduction of DES, the rates of restenosis and target-vessel revascularization have dropped below 10%. However, angioscopy showed that the restenosis site in patients treated with DES looked like vulnerable plaque [22]. Therefore, statins could still be useful after PCI even in patients treated with DES.…”

Coronary Artery Discoveries Made Using Direct Angioscopic Visualization: Fifteen Years of Experience and Further Expectations

“…Thick, white neointima covered the ISR lesion, without restenosis being observed at the follow-up examination. 20) This case suggests that angioscopic observation directly impacts the choice of an effective therapy.…”