Restenosis in Peripheral Arteries Donald B Reid Glasgow, Scotland

No Disclosures

Definition Recurrent stenosis in a vessel following treatment Reduction in the circumference of more than 50% of vessel wall

Journal of Endovascular Therapy

Endovascular Restenosis Fishmouth

Histopathology of Restenosis Two major mechanisms Early : trauma to vessel wall triggers the clotting cascade to form a thrombus Late : restenosis where normal mechanisms which limit inflammation fail leading to fibroproliferative reaction and neointimal hyperplasia

Aetiology Age Diabetes Small vessels Renal failure Women Previous restenosis Altered haemodynamic factors Bio-incompatibility of graft or stent materials

Anatomical Features Carotid artery Iliac artery Femoral artery

Investigations Clinical examination Doppler ultrasound CTA (MRA) Arteriography Intravascular ultrasound Arterial pressure gradient

Femoral Stent Restenosis Courtesy P Peeters

Cryotherapy PolarCath Balloon

Atherectomy Jetstream Pathway Device

Laser for SFA In-Stent Restenosis PATENT STUDY Laser for SFA In-Stent Restenosis Schmidt A, Zeller T, Sievert H et al. J Endovasc Ther 2014; 21: 52-60

“Reline” for In-Stent Restenosis Fishmouth Reline Study Randomised Trial Viabahn vs PTA

Drug Eluting Stents

Randomised controlled trial The SIROCCO Trial Randomised controlled trial Sirolimus Smart Stent vs Bare Metal Smart Stent Duda SH, Bosiers M, Lammer J et al. J Endovasc Ther 2006; 13: 701-710

In-Stent Restenosis at 1 year Drug Eluting Balloons DEBATE-ISR Study Paclitaxil DEB vs PTA 19.5% vs 71.8% In-Stent Restenosis at 1 year P<0.05 Liistro F, Angioli P, Porto I et al. J Endovasc Ther 2014; 21: 1-8.

Restenosis Conclusions Restenosis is a significant complication after endovascular surgery Diagnostic Imaging can give Early Detection Difficult to treat successfully 18

Restenosis Conclusions Prevention with risk factor reduction : Anti-hypertensives, Statins, Anti-platelets Non Smoking Drug Eluting Stents and Stent Design 19

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Iliac Stent Restenosis Recurrent symptoms Clinical Examination Doppler U/S CTA PTA + IVUS

Carotid Endarterectomy Restenosis Carotid Restenosis

Carotid Endarterectomy Restenosis

Carotid Endarterectomy Restenosis Post Stent

Carotid Endarterectomy Restenosis A 10 year retrospective study of 192 patients with restenosis following carotid endarterectomy surgery treated by repeat surgery or stenting Repeat Surgery n = 72 Carotid Stenting n = 120 AbuRhama et al., 2010

AbuRhama et al., 2010 30 day Perioperative Results STENT N=120 Total REPEAT SURG N=72 STENT N=120 Total (N=192) P value Ipsilateral Stroke 2 (3%) 1 (1%) 3 (2%) 0.5573 Ipsilateral TIA 3 (3%) 4 (2%) 1 Death MI Bleeding 1 (0.5%) Periop complication 14 (19%) 2 (2%) 16 (8%) <0.0001 Cranial nerve injury 10 (14%) 10 (5%) AbuRhama et al., 2010

AbuRhama et al., 2010 30 day Perioperative Results STENT N=120 Total REPEAT SURG N=72 STENT N=120 Total (N=192) P value Ipsilateral Stroke 2 (3%) 1 (1%) 3 (2%) 0.5573 Ipsilateral TIA 3 (3%) 4 (2%) 1 Death MI Bleeding 1 (0.5%) Periop complication 14 (19%) 2 (2%) 16 (8%) <0.0001 Cranial nerve injury 10 (14%) 10 (5%) AbuRhama et al., 2010

Carotid Restenosis REPEAT SURGERY STENT AbuRhama et al., 2010

Carotid Stent Restenosis Conclusions Carotid Stent Restenosis REPEAT SURGERY STENT AbuRhama et al., 2010

Atherectomy Jetstream Pathway Device