Mechanisms of drug-eluting stent restenosis
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INVITED REVIEW ARTICLE
Mechanisms of drug‑eluting stent restenosis Jiro Aoki1 · Kengo Tanabe1 Received: 5 November 2020 / Accepted: 6 November 2020 © Japanese Association of Cardiovascular Intervention and Therapeutics 2020
Abstract Drug-eluting stents (DES) were developed to overcome in-stent restenosis (ISR), which has long been considered the main complication limiting the long-term efficacy of coronary stenting. New-generation DES which composed of advanced stent design with and without specific biocompatible polymer contributes a reduction of the incidence of ISR to rate ranging from 5 to 10%. The precise reasons of DES restenosis are still controversial and not fully understood. Angiographic and coronary images at the index procedure, systemic status of patients, medications, and intracoronary imaging at ISR site are all considered to find the possible mechanisms of DES restenosis. Multiple biological, genetic, mechanical, and technical factors might intricately contribute to DES restenosis. Biological and genetic factors of ISR are not able to be sufficiently modified by the current medical approaches. Tailored treatments avoiding mechanical and technical factors of ISR are required to reduce DES restenosis. Elucidation of DES restenosis leads to further improvement in the current DES system and finds the optimal approach to treat DES restenosis. The possible mechanisms of DES restenosis are discussed in this review. Keywords Mechanism · Restenosis · Stent
Introduction Drug-eluting stents (DES) were developed to overcome instent restenosis (ISR), which has long been considered the main complication limiting the long-term efficacy of coronary stenting [1]. Incidence of ISR has been reported in up to 30% after bare-metal stent (BMS) implantation. When the initial clinical trials of the first DES reported the zero-level rates of restenosis [2], we expected that we would overcome this powerful enemy and open the doors to a world without restenosis. Nevertheless, the small number of patients with ISR after current DES treatment still exists. DES cannot completely cut the Gordian knot of ISR. New-generation DES which composed of advanced stent design with and without specific biocompatible polymer contributes a reduction of the incidence of ISR to rate ranging from 5 to 10% [3–5]. Traditionally, ISR was believed as benign. However, recent study suggests approximately 50% of ISR cases present with unstable angina. Among those, 18.7% of cases develop NSTEMI, and 8.5% of cases develop STEMI. ISR * Jiro Aoki [email protected] 1
Division of Cardiology, Mitsui Memorial Hospital, 1 Kanda‑Izumicho, Chiyoda‑ku, Tokyo 101‑8643, Japan
cannot be still ignored in the current DES era [6]. Although the low frequency of DES restenosis makes it difficult to fully investigate this syndrome, many studies have been conducted or are ongoing to find the mechanism of DES restenosis. Elucidation of DES restenosis leads to further improvement in the current DES system and finds the optimal approach to treat DES restenosis. There
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