Treatment strategies for coronary in-stent restenosis: systematic review and hierarchical Bayesian network meta-analysis of 24 randomised trials and 4880 patients

Dear Sir,

It is interesting to peruse this thought-provoking article.(1) Somehow in contemporary practice there is tendency to perform percutaneous coronary interventions (PCI) for lesions/patients for whom coronary artery bypass grafting (CABG) is clearly documented to be superior, particularly in the long-term. Patients and their care-givers must be properly educated and motivated to choose the best option. However, as heart-team approach is either absent or less effective in most hospitals; patients are offered PCI for lesions/patients with high risk of future restenosis (diabetic patients with calcified and diffuse lesions, etc.). In day-to-day practice most clinical restenosis is encountered in such patients.

There is sufficient data to prove that the results of the treatment of restenosis with PCI (2) or CABG (3) are far inferior even in the best hands/centers.

Therefore, the best treatment of restenosis is prevention of restenosis by thoughtful planning (keeping the interests of the patients above all), including heart-team approach, and a clear understanding that revascularization (PCI using drug eluting stents/drug coated balloons/ drug coated cutting balloons/ or CABG) is much inferior option.

References:
1. BMJ 2015;351:h 5392
2. Mehran R, Dangas G, Abizaid AS, et al. Angiographic patterns of in-stent restenosis.Classification and implications for long-term outcomes. Circulation 1999;100:1872-1878
3. Carnero-Alcazar M, Alswies A, Villagran Medinilla E, et al. Mid-term outcomes after off-pump coronary surgery in patients with prior intracoronary stents. Eur J Cardiothorac Surg 2015; 41(6) :1295-303