Introduction: In-stent restenosis (ISR) of drug-eluting stents (DES) continues to be a therapeutic challenge and its frequency increases over time. Intracoronary vascular brachytherapy (VBT) was initially approved for treatment of bare-metal stent ISR but its main indication is now for recurrent DES-ISR. The aim of this study was to compare the efficacy of VBT to repeat DES and conventional balloon angioplasty (CBA) for treatment of DES-ISR in the contemporary DES era.
Methods: We performed a retrospective analysis of patients undergoing treatment for DES-ISR from 2003 to 2016. The patients were divided based on treatment of ISR: CBA, DES, or VBT.
Results: 1,137 patients were treated for DES-ISR. 329 (29%) were treated with CBA, 524 (46%) were treated with DES, and 284 (25%) with VBT. The VBT group had higher incidence of prior bypass surgery (56% vs 36% and 34% in the CBA and DES group, respectively, p<0.001). The CBA group had a higher incidence of heart failure (24% vs 19% and 13% in the DES and VBT group, respectively, p=0.003). There was no difference in presentation of unstable angina (58%). Patients treated with CBA or DES presented with myocardial infarction (MI) more than the VBT group (11% for both vs 4%, p<0.001). However, the VBT group had significantly more complex lesions (44% Type C vs 34% and 30% in the CBA and DES groups, p<0.001). One-year rate of composite death, Q-wave MI, and target lesion revascularization were similar for the DES and VBT groups (15% and 16%, respectively) but higher in the CBA group (30%, p<0.001). Rates of stent thrombosis were low (0% in CBA, 0.2% in DES, and 0.4% in VBT, p=0.733).
Conclusions: DES-ISR remains a therapeutic challenge in the contemporary DES era. Treatment of ISR with VBT out-performs CBA and is comparable to repeat DES at one year. VBT should be considered for treatment of ISR, especially for patients not suitable for additional layers of metallic stent.