Re: RESTENOSIS

Posted By BOB on May 11, 1998 at 12:24:45:

In Reply to: Re: RESTENOSIS posted by CCF Cardio MD-SGM on May 01, 1998 at 19:47:05:







: <  THANKS FOR THE INFORMATION, I WILL CONSIDER BEING EVALUATED FOR A
"BRACHYTHERAPY" IF I AGAIN DEVELOP RESTENOSIS.
I'm a 53 year old male who had MIDCAB on the LAD for a 100% blockage
in Mar of 96.  At that time my RCA was 50-60% blocked. In Jan 97 my RCA
was found to be 100% blocked, a angioplasty was done. In 12 weeks I was
back again for a angioplasty and stent implacement, same spot. In 16 weeks back again for
another angioplasty and stent of the RCA, same spot. In 20 weeks restenosis
again occurred in the middle of the stents, laser was used to remove
blockage and angioplasty performed.  Its been 12 weeks since the last
procedures and I'm concerned it will block again. My lipids are now the
best they ever were LDL 54, HDL 44, TRI 129, lp(a) 62.  Questions; Is
my case common as far as restenosis? How many times can these type
of procedures be done in the same general area of a coronary  artery?
If it happens again would a bypass be recommended, if so, would the odds
be better that restenosis would not occur? Any new procedures that you
feel may work in my case? Would you recommend having another laser or
stent if it happened in the same general area? Do I need to change
hospitals and surgeons? Thank You!!      



______


: Dear Bob,
As you know, coronary artery blockages can often be treated with either surgical bypass grafting, or via catheters-- known as percutaneous coronary intervention, or PCI.  We've known for some time that one treatment strategy is often not clearly superior to the other, and that both have pros and cons.  In your case, the right coronary artery lesion developed after the surgery, and it was quite reasonable to perform PCI of this particular stenosis.  Repeat surgery for single vessel disease of the right coronary artery, in the presence of a functioning graft to the LAD, is somewhat risky and likely offers minimal net benefit.  This is because survival over the long run is much more intimately associated with a functioning LAD graft, as this artery provides blood to a majority of the heart muscle, and thus the right coronary artery problem is deemed less crucial.
Unfortunately, I believe that you have experienced some of the most disappointing results of PCI. This is not to say that your doctors have not done a valiant job of addressing the recurrent problems in the right coronary artery.  Rather, it is unfortunate that you have experienced the extreme of the "restenosis" problem. As you are aware,  restenosis is the bane of PCI, with up to 30 or 40 percent of individuals experiencing a recurrence of their blockage at the site of angioplasty or stent.  We believe that these results have improved as a result of better devices, stents, and various medications (Reopro, ticlid, cholesterol-lowering meds).  However, some patients continue to experience disappointing results.   We're aggressively looking for a more satisfying solution to this problem.  However, for the 60 or 70 percent of people that have PCI without restenosis,  angioplasty or stenting helped to avoid the major problems associated with full recovery from bypass surgery.  
At this point, what you describe is recurrent in-stent restenosis.  This is a serious and difficult problem.  One extreme would be to perform another bypass surgery, if the current lesion again causes problems, although as I mentioned, the net benefit from surgery on one vessel in the presence of a functioning LAD graft is low.  With repeat surgery, there is concern about inadvertently damaging the LAD graft.  This would clearly be undesirable.  Percutaneous techniques (catheter based) to address recurrent in-stent restenosis include the laser treatment you received, as well as a promising new technique known as "brachytherapy".  This latter option is new and investigational, although preliminary results are excellent.  It involves placing a small source of radiation within the stent, thus focally delivering the radiation to the tissue of the vessel that is responsible for the restenosis.  This radiation is not harmful to the body, and acts in a very local manner, right at the site of the lesion.  Radiation has been shown to reduce the rate of restenosis at sights of PCI.  At this time, brachytherapy is undergoing investigation at large medical centers around the country.  You might consider enrolling in a such a study if your current attempt at revascularization again results in restenosis.  Feel free to contact the Cleveland Clinic Foundation, Dr. Ellis, at Desk F25, 1 800 CCF-CARE, to be evaluated for the therapy,  should it become necessary.
Information in the Heart Forum is for general purposes.  Specific diagnoses and therapies can  only be provided by your physician.