Clinical Review

New approaches to preventing restenosis

BMJ 2003; 327 doi: 10.1136/bmj.327.7409.274 (Published 31 July 2003)
Cite this as: BMJ 2003;327:274

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  1. Balram Bhargava, senior consultant (balrambhargava@yahoo.com)1,
  2. Ganesan Karthikeyan, consultant1,
  3. Alexandre S Abizaid, consultant2,
  4. Roxana Mehran, consultant3
  1. 1Department of Cardiology, Cardiothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi 110029, India
  2. 2Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
  3. 3Cardiovascular Research Foundation, New York, NY, USA
  1. Correspondence to: B Bhargava
  • Accepted 3 July 2003

For over a quarter of a century percutaneous coronary interventions have been used to treat patients with coronary artery disease, yet restenosis continues to be a problem. This review discusses the advances being made to overcome restenosis, particularly the development of drug eluting stents

Introduction

Andreas Gruntzig pioneered percutaneous transluminal coronary angioplasty in 1977.1 Since then, percutaneous coronary interventions have revolutionised the treatment of patients with symptoms of coronary artery disease, sparing them the need for surgical revascularisation. In the United States, the number of percutaneous interventions performed each year is nearly double that of coronary artery bypass surgery.w1 There have been three phases in the evolution of percutaneous interventions (see box 1), but in each restenosis has been a problem. It seems the next (and optimistically the final) phase is the development of drug eluting stents—that is, stents used for the local delivery of drugs (table).

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Restenosis and instent restenosis, 1977-2002

Sources and selection criteria

The information in this review is based on the results of a Medline search using the key words coronary angioplasty, restenosis, instent restenosis, drug eluting stents, and intracoronary brachytherapy, and articles from the authors' personal collection. Cross references and related articles were accessed when necessary.

Restenosis

Restenosis is the maladaptive response of the coronary artery to injury. The simplest and most widely used definition of restenosis is a diameter stenosis of 50% at follow up. Restenosis occurs in 20-50% of patients after balloon angioplasty and in 10-30% of patients receiving a stent. Three distinct processes are involved—recoil of the vessel, neointimal proliferation, and early thrombus formation. The relative contribution of each of these depends on the type of injury. About three quarters of the lumen loss after balloon angioplasty is due to vessel recoil and the rest to neointimal proliferation,2 whereas coronary stenting virtually eliminates vessel recoil, …

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