Comparative characteristics and revascularization strategy of in-stent restenosis after percutaneous coronary intervention with different types of stents

   Objective: to perform a comparative analysis of characteristics of coronary arteries in-stent restenosis and to evaluate effectiveness of repeat revascularization using drug-eluting stents (DES) and drug-eluting balloon angioplasty (DEB) in patients with restenosis depending on the presence/absence of type 2 diabetes.

   Materials and methods: the study included 122 patients (age 59.7 ± 4.9 years) treated for in-stent restenosis after primary percutaneous coronary intervention (PCI) using bare-metal stents (BMS) and bare-metal carbon-coated stents (BMCCS) for non-ST-segment elevation acute coronary syndrome (ACS) at the Republican Clinical Hospital named after N.A. Semashko. Group 1 included 55 patients without a history of diabetes, group 2 included 67 patients with type 2 diabetes. Patients in both groups were divided into 2 subgroups, which underwent repeat revascularization with one of the options - using a new generation DES (stent system with everolimus and sirolimus) or using DEB coated with paclitaxel.

   Results: patients in both groups with BMS had a larger length and diameter of in-stent restenosis compared to patients with BMCCS. Patients with diabetes had a significant increase in serum concentrations of endocan, platelet-derived growth factor (PDGF) and C-reactive protein (CRP) compared to patients without diabetes. The following relationships were established during the correlation analysis: group 1 - endocan level with length of restenosis (r = 0.41, p < 0.05), CRP level with length (r = 0.36, p < 0.05) and diameter of restenosis (r = 0.33, p < 0.05); group 2 - endocan level with length (r = 0.51, p < 0.05) and diameter of restenosis (r = 0.54, p < 0.05), PDGF level with diameter of restenosis (r = 0.39, p < 0.05). Twelve months follow-up after repeat revascularization revealed no significant differences in the incidence of major cardiovascular events in group 1 patients with implanted DES and DEB. However, in patients with diabetes, the rate of recurrent restenosis (17.1 %) and stent thrombosis (8.6 %) after revascularization with DES was significantly higher compared to patients with DEB (p < 0.05).

   Conclusion: type 2 diabetes significantly worsens the prognosis after PCI, increasing inflammatory and proliferative processes, and appears to be an important modifier of outcomes after repeat revascularization of in-stent restenosis. In patients without type 2 diabetes the use of both DES and DEB for in-stent restenosis demonstrated comparable efficacy and safety during 1-year follow-up. At the same time, in patients with type 2 diabetes DES implantation showed worse results compared to patients with DEB implantation.

1. Ahmad E, Lim S, Lamptey R, Webb DR, Davies MJ. Type 2 diabetes. Lancet. 2022;400(10365):1803-1820. DOI: 10.1016/S0140-6736(22)01655-5

2. Sun H, Saeedi P, Karuranga S, Pinkepank M, Ogurtsova K, Duncan BB, et al. IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022;183:109119. DOI: 10.1016/j.diabres.2021.109119

3. Sun X, Zhang C, Ma Y, He Y, Zhang X, Wu J. Association between diabetes mellitus and primary restenosis following endovascular treatment: a comprehensive meta-analysis of randomized controlled trials. Cardiovasc Diabetol. 2024;23(1):132. DOI: 10.1186/s12933-024-02201-6

4. Tanner R, Farhan S, Giustino G, Sartori S, Feng Y, Hooda A, et al. Impact of diabetes mellitus on clinical outcomes after first episode in-stent restenosis PCI: Results from a large registry. Int J Cardiol. 2024;401:131856. DOI: 10.1016/j.ijcard.2024.131856

5. Zhang J, Zhang Q, Zhao K, Bian YJ, Liu Y, Xue YT. Risk factors for in-stent restenosis after coronary stent implantation in patients with coronary artery disease: A retrospective observational study. Medicine (Baltimore). 2022;101(47):e31707. DOI: 10.1097/MD.0000000000031707

6. Shevchenko Y.L., Ermakov D.Y., Maslennikov M.A., Ul’bashev D.S., Vakhrameyeva A.Y. Tactics of Endovascular Treatment of Patients with Coronary Heart Disease with Recurrent Coronary In-Stent Restenosis Using Second- and Third-Generation Stent Systems and Paclitaxel-Coated Balloon Catheters. I.P. Pavlov Russian Medical Biological Herald. 2024;32(1):5-16. (In Russ.) DOI: 10.17816/PAVLOVJ625996

7. Di Maio M, Esposito L, Silverio A, Bellino M, Cancro FP, De Luca G, et al. Prognostic significance of the SYNTAX score and SYNTAX score II in patients with myocardial infarction treated with percutaneous coronary intervention. Catheter Cardiovasc Interv. 2023;102(5):779-787. DOI: 10.1002/ccd.30842

8. Giustino G, Colombo A, Camaj A, Yasumura K, Mehran R, Stone GW, et al. Coronary In-Stent Restenosis : JACC State-of-the-Art Review. J Am Coll Cardiol. 2022;80(4):348-372. DOI: 10.1016/j.jacc.2022.05.017

9. Konigstein M, Redfors B, Zhang Z, Kotinkaduwa LN, Mintz GS, Smits PC, et al. Utility of the ACC/AHA Lesion Classification to Predict Outcomes After Contemporary DES Treatment: Individual Patient Data Pooled Analysis From 7 Randomized Trials. J Am Heart Assoc. 2022;11(24):e025275. DOI: 10.1161/JAHA.121.025275

10. Bazylev V.V., Shmatkov M.G., Pianzin A.I., Morozov Z.A. Long-term results of using domestic coronary stents with bioinert carbon coating, «Nanomed». Journal Diagnostic & interventional radiology. 2020; 14(1); 47-54. DOI: 10.25512/DIR.2020.14.1.05.

11. Cao Z, Liu Y, Wang Y, Leng P. Research progress on the role of PDGF/PDGFR in type 2 diabetes. Biomed Pharmacother. 2023;164:114983. DOI: 10.1016/j.biopha.2023.114983

12. Klisic A, Patoulias D. The Role of Endocan in Cardiometabolic Disorders. Metabolites. 2023;13(5):640. DOI: 10.3390/metabo13050640

13. Jakubiak GK, Pawlas N, Cieślar G, Stanek A. Pathogenesis and Clinical Significance of In-Stent Restenosis in Patients with Diabetes. International Journal of Environmental Research and Public Health. 2021;18(22):11970. DOI: 10.3390/ijerph182211970

14. Giacoppo D, Alfonso F, Xu B, Claessen BEPM, Adriaenssens T, Jensen C, et al. Drug-Coated Balloon Angioplasty Versus Drug-Eluting Stent Implantation in Patients With Coronary Stent Restenosis. J Am Coll Cardiol. 2020;75(21):2664-2678. DOI: 10.1016/j.jacc.2020.04.006