title: Management of distal/bifurcation left main restenosis after drug eluting stents implantation: single center experience.
abstract: OBJECTIVE
  Restenosis after drug eluting stent (DES) implantation in the distal/bifurcation left main (DBLM) remains challenging to manage. The aim of this study was to assess the in-stent restenosis (ISR) after DES implantation in DLM and to evaluate current management strategy.
  
  
  METHODS
  The medical records of patients referred for LM distal/bifurcation percutaneous coronary interventions (PCI) from the same Cardiology Unit in the January 2007 to December 2012 period were reviewed for PCI technique, stent type, restenosis type, restenosis treatment and management (CABG, balloon angioplasty only, alternative DES implant, drug eluting balloon angioplasty).
  
  
  RESULTS
  Fourteen patients (5 females, mean age 75.1±8.3years) out of 89 (15.7%) having undergone a percutaneous coronary interventions on DBLM with DES, developed restenosis (everolimus stents in 10 patients, zotarolimus stents in 4 patients). Technique used at the first implant included stenting of the main branch in 4 patients, culottes stenting in 6 patients and T-stent in 4 patients. The mean time elapsed from the first angioplasty and ISR intervention was 7.6±3.6months. Restenosis treatments included: implantation of a different DES (in 3 patients), implantation of a bare-metal stent (in 2 patients), simple balloon angioplasty (in 4 patients), and drug-eluting balloon (5 patients). At 6-month angiographic control second restenosis rate was 14.2%. After a mean follow-up of 38.5±24.4months the target vessel revascularization was 14.3%: surgery was the final choice in two patients due to recurrent restenosis. Incidence of major adverse cardiac event was 28.5%.
  
  
  CONCLUSIONS
  The occurrence of restenosis after DBLM following DES implantation is not frequent but remains difficult to manage. In our small anecdotal series, all the different strategies including implantation of different DES, balloon angioplasty, bare-metal stent implantation and drug-eluting balloon angioplasty appeared equally effective in maintaining arterial patency.
authors.affiliation: Interventional Cardiology Unit, Division of Cardiology, Rovigo General Hospital, Rovigo, Italy. Electronic address: jackyheart71@yahoo.it.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Rigatelli
authors.affiliation: Interventional Cardiology Unit, Division of Cardiology, Rovigo General Hospital, Rovigo, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Cardaioli
authors.affiliation: Interventional Cardiology Unit, Division of Cardiology, Rovigo General Hospital, Rovigo, Italy.
authors.forename: Fabio
authors.initials: F
authors.lastname: Dell'Avvocata
authors.affiliation: Interventional Cardiology Unit, Division of Cardiology, Rovigo General Hospital, Rovigo, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Giordan
authors.affiliation: Interventional Cardiology Unit, MedicaKor Hospital, Ruse, Bulgaria.
authors.forename: Dobrin
authors.initials: D
authors.lastname: Vassilev
authors.affiliation: Interventional Cardiology Unit, Division of Cardiology, Rovigo General Hospital, Rovigo, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Fraccaro
authors.affiliation: Interventional Cardiology Unit, Division of Cardiology, Rovigo General Hospital, Rovigo, Italy.
authors.forename: Loris
authors.initials: L
authors.lastname: Roncon
authors.affiliation: Institute of Cardiac Surgery, Verona University School of Medicine and Surgery, Verona, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Faggian
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation*; D002317:Cardiovascular Agents / Q000008:administration & dosage; D017023:Coronary Angiography; D023921:Coronary Stenosis / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D054855:Drug-Eluting Stents; D000068338:Everolimus / Q000008:administration & dosage; D005260:Female; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D012307:Risk Factors; D020123:Sirolimus / Q000008:administration & dosage / Q000031:analogs & derivatives; D013997:Time Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional; D014654:Vascular Patency
chemical_list: D002317:Cardiovascular Agents; D000068338:Everolimus; C489443:zotarolimus; D020123:Sirolimus
keywords: Angioplasty; Coronary angiography; Coronary artery disease; Interventional; Surgery