Guidance on management of in-stent restenosis and stent thrombosis

The Society for Cardiovascular Angiography & Interventions (SCAI) today released an expert consensus on the management of in-stent restenosis and stent thrombosis. The statement was published online in the Journal of the Society for Cardiovascular Angiography & Interventions (JSCAI).

In-stent restenosis is a blockage or narrowing that comes back in the portion of the coronary artery previously treated with a stent and remains a common clinical problem despite numerous improvements in stent design and polymer coatings in recent years. In addition to significant health care costs, it is also associated with an increased risk of death and re-hospitalization. Stent thrombosis causes abrupt closure of the stented artery, and therefore carries a high risk of myocardial infarction and death.

In the document, the writing group suggests updated practical algorithmic approaches to in-stent restenosis and stent thrombosis. A pragmatic outline of assessment and management of patients presenting with stent failure is presented and a new SCAI classification that is time-sensitive with mechanistic implications of in-stent restenosis is proposed. Emphasis is placed on frequent use of intracoronary imaging and assessment of timing to determine the precise etiology, as that information is crucial to guide selection of the best treatment option.

"As always, our first goal is to follow the best evidence to try to prevent or decrease risk of in-stent restenosis or stent thrombosis," said Amif Lofti, MD, lead author of the manuscript and Chief of Cardiology at Baystate Health. "The goal of this document was to develop a meaningful algorithm, based on the best current available evidence, for the interventional cardiologist in the management of in-stent restenosis and stent thrombosis."

SCAI recommends image-guided coronary stenting at the time of initial implantation to minimize the occurrence of stent failure. When in-stent restenosis and stent thrombosis is encountered, imaging should be strongly considered to optimize the subsequent approach.