What are the implications of prodromal (prod) Left Anterior Descending (LAD) artery in-stent restenosis?

From the Guidelines

For a patient with in-stent restenosis in the left anterior descending (LAD) coronary artery, the recommended approach is repeat revascularization, typically with drug-eluting balloon angioplasty or implantation of a new drug-eluting stent, as suggested by the most recent guidelines 1. The choice between these options depends on the pattern of restenosis, with focal restenosis often managed with drug-eluting balloons while diffuse restenosis may require a new drug-eluting stent. Following revascularization, dual antiplatelet therapy (DAPT) with aspirin 81mg daily indefinitely plus a P2Y12 inhibitor such as clopidogrel 75mg daily for at least 6-12 months is essential, as supported by previous studies 1. Optimizing medical therapy is also crucial, including:

• High-intensity statin therapy (atorvastatin 40-80mg or rosuvastatin 20-40mg daily)
• Blood pressure control (target <130/80 mmHg)
• Diabetes management if applicable (target HbA1c <7%) Lifestyle modifications including smoking cessation, regular exercise, and dietary changes are important complementary measures. ISR occurs due to neointimal hyperplasia, which is an exaggerated healing response to vessel injury during stenting, and drug-eluting technologies help inhibit this proliferative process to prevent recurrent restenosis, as noted in earlier guidelines 1. However, the most recent and highest quality study 1 takes precedence in guiding clinical decision-making for patients with prod LAD in stent restenosis.

From the Research

Prod LAD in Stent Restenosis

• Prod LAD, or left anterior descending artery, is a critical blood vessel that supplies blood to the heart muscle.
• Stent restenosis, or the re-narrowing of a stent, can occur in the LAD and is a significant clinical challenge 2, 3, 4.
• The pathophysiology of in-stent restenosis (ISR) is complex and involves the proliferation of smooth muscle cells, inflammation, and the formation of new tissue 3, 4.
• Treatment options for ISR in the LAD include plain old balloon angioplasty (POBA), rotational atherectomy, vascular brachytherapy (VBT), bare metal stents (BMS), drug-coated balloons (DCBs), and drug-eluting stent (DES) placement 3, 4.
• Drug-coated balloons and stent reimplantation are the current mainstays of treatment for ISR, and the choice of treatment should be based on clinical background and lesion morphology 4.
• Medical management after coronary stent implantation, including dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, is crucial to reduce the risk of stent thrombosis and subsequent cardiovascular events 5, 6.

Risk Factors and Clinical Presentation

• The clinical presentation and symptoms of ISR vary considerably among patients, from stable angina to unstable angina and acute myocardial infarction 3.
• Risk factors for ISR include diabetes, renal failure, and complex lesion morphology 3, 4.
• Coronary angiography is the gold standard for evaluating the morphology of ISR, although computed tomography angiography is emerging as an alternative noninvasive modality to evaluate the presence of ISR 4.

Treatment Outcomes

• The most efficacious therapy for ISR depends on patient and lesion characteristics, but drug-eluting stents and drug-coated balloons yield the most successful angiographic and clinical results 3, 4.
• Complete apposition with balloon dilation followed by a DCB is a feasible treatment option for ISR triggered by longitudinal stent deformation (LSD) 2.
• Low-dose aspirin remains an important antiplatelet in the management of chronic coronary syndromes, including patients with ISR 6.