title: Symptomatic failure after sirolimus-eluting stent implantation: a rare but challenging condition.
abstract: BACKGROUND
  Limited information is available regarding restenosis after implantation of a sirolimus-eluting stent (SES).
  
  
  OBJECTIVE
  To report on angiographic characteristics, clinical presentation and treatment of this particularly complex type of coronary lesion.
  
  
  RESULTS
  A total of 1424 SES were implanted in 1159 patients (average 1.2 per patient) for chronic or acute coronary syndromes in the University Hospital of Siena (Siena, Italy), which is a tertiary centre. Symptomatic in-SES restenosis was observed in 26 patients (2.2%) at 10+/-5 months (median eight months, range four to 23 months) following the initial intervention. In-SES restenosis was associated with stable angina in 16 patients, acute myocardial infarction in three patients and unstable angina in seven patients. Two patients had restenosis in two separate SES. Conditions often associated with in-SES restenosis included treatment of chronic total occlusion, geographic miss or in-stent restenosis during the index procedure. Among the first 20 patients, those with focal, in-body SES (type Ic) restenosis received balloon-only angioplasty, and patients with other patterns received repeat SES implantation. Clinical and angiographic follow-up (average 16+/-7 months) recorded one death (noncardiac) in the balloon-only group and four cases of unstable angina (three due to relapsing in-SES restenosis in the balloon-only group and the fourth due to a de novo lesion). Follow-up quantitative angiography showed a higher incidence of binary restenosis after balloon-only treatment (57% versus 17%; P<0.05), as well as higher lumen loss and loss index (P<0.05).
  
  
  CONCLUSIONS
  Restenosis after SES implantation occurs more commonly in a focal pattern in-body or at the proximal edge of the stent. Repeat SES implantation appears to be a safer and more effective therapeutic choice than balloon-only angioplasty.
authors.affiliation: Department of Internal, Cardiovascular and Geriatric Medicine, University Hospital of Siena, Italy. tommaso.gori@utoronto.ca
authors.forename: Massimo
authors.initials: M
authors.lastname: Fineschi
authors.forename: Tommaso
authors.initials: T
authors.lastname: Gori
authors.forename: Carlo
authors.initials: C
authors.lastname: Pierli
authors.forename: Stefano
authors.initials: S
authors.lastname: Casini
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Sinicropi
authors.forename: Alberto
authors.initials: A
authors.lastname: Buti
authors.forename: Alessandro
authors.initials: A
authors.lastname: Iadanza
authors.forename: Achille
authors.initials: A
authors.lastname: Bravi
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D004868:Equipment Failure; D005260:Female; D005500:Follow-Up Studies; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy*; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000628:therapy; D011859:Radiography; D012189:Retrospective Studies; D020123:Sirolimus / Q000008:administration & dosage*; D015607:Stents / Q000009:adverse effects*; D016896:Treatment Outcome
chemical_list: D007166:Immunosuppressive Agents; D020123:Sirolimus