title: Treatment strategies for coronary in-stent restenosis: systematic review and hierarchical Bayesian network meta-analysis of 24 randomised trials and 4880 patients.
abstract: OBJECTIVE
  What is the most safe and effective interventional treatment for coronary in-stent restenosis?
  
  
  METHODS
  In a hierarchical Bayesian network meta-analysis, PubMed, Embase, Scopus, Cochrane Library, Web of Science, ScienceDirect, and major scientific websites were screened up to 10 August 2015. Randomised controlled trials of patients with any type of coronary in-stent restenosis (either of bare metal stents or drug eluting stents; and either first or recurrent instances) were included. Trials including multiple treatments at the same time in the same group or comparing variants of the same intervention were excluded. Primary endpoints were target lesion revascularisation and late lumen loss, both at six to 12 months. The main analysis was complemented by network subanalyses, standard pairwise comparisons, and subgroup and sensitivity analyses.
  
  
  CONCLUSIONS
  Twenty four trials (4880 patients), including seven interventional treatments, were identified. Compared with plain balloons, bare metal stents, brachytherapy, rotational atherectomy, and cutting balloons, drug coated balloons and drug eluting stents were associated with a reduced risk of target lesion revascularisation and major adverse cardiac events, and with reduced late lumen loss. Treatment ranking indicated that drug eluting stents had the highest probability (61.4%) of being the most effective for target lesion vascularisation; drug coated balloons were similarly indicated as the most effective treatment for late lumen loss (probability 70.3%). The comparative efficacy of drug coated balloons and drug eluting stents was similar for target lesion revascularisation (summary odds ratio 1.10, 95% credible interval 0.59 to 2.01) and late lumen loss reduction (mean difference in minimum lumen diameter 0.04 mm, 95% credible interval -0.20 to 0.10). Risks of death, myocardial infarction, and stent thrombosis were comparable across all treatments, but these analyses were limited by a low number of events. Trials had heterogeneity regarding investigation periods, baseline characteristics, and endpoint reporting, with a lack of information at long term follow-up. Direct and indirect evidence was also inconsistent for the comparison between drug eluting stents and drug coated balloons.
  
  
  CONCLUSIONS
  Compared with other currently available interventional treatments for coronary in-stent restenosis, drug coated balloons and drug eluting stents are associated with superior clinical and angiographic outcomes, with a similar comparative efficacy.
  
  
  BACKGROUND
  This study received no external funding. The authors declare no competing interests. No additional data available.
authors.affiliation: Department, Ferrarotto Hospital, Catania, Italy.
authors.forename: Daniele
authors.initials: D
authors.lastname: Giacoppo
authors.affiliation: Department, Ferrarotto Hospital, Catania, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Gargiulo
authors.affiliation: Department, Ferrarotto Hospital, Catania, Italy.
authors.forename: Patrizia
authors.initials: P
authors.lastname: Aruta
authors.affiliation: Department, Ferrarotto Hospital, Catania, Italy Department of General Surgery and Medical Surgical Specialties, Ferrarotto Hospital, University of Catania, 95124 Catania, Italy.
authors.forename: Piera
authors.initials: P
authors.lastname: Capranzano
authors.affiliation: Department, Ferrarotto Hospital, Catania, Italy Department of General Surgery and Medical Surgical Specialties, Ferrarotto Hospital, University of Catania, 95124 Catania, Italy.
authors.forename: Corrado
authors.initials: C
authors.lastname: Tamburino
authors.affiliation: Department, Ferrarotto Hospital, Catania, Italy Department of General Surgery and Medical Surgical Specialties, Ferrarotto Hospital, University of Catania, 95124 Catania, Italy dcapodanno@gmail.com.
authors.forename: Davide
authors.initials: D
authors.lastname: Capodanno
mesh_terms: D001499:Bayes Theorem; D023903:Coronary Restenosis / Q000628:therapy*; D054855:Drug-Eluting Stents; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D009204:Myocardial Revascularization / Q000379:methods; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D015607:Stents / Q000009:adverse effects
chemical_list: D007166:Immunosuppressive Agents