Meta-Analysis Demonstrates Efficacy of Various Percutaneous Interventions for In-Stent Restenosis

November 20, 2015—Ankur Sethi, MBBS, et al conducted a comprehensive network meta-analysis of randomized controlled trials to determine the efficacy of various percutaneous interventions for in-stent restenosis (ISR). The findings are available online ahead of print in Circulation: Cardiovascular Interventions.

As noted by the investigators, the background of the study is that ISR remains a difficult problem in interventional cardiology and the relative efficacy and safety of available interventions is not clear.

As summarized in Circulation: Cardiovascular Interventions, the investigators’ network meta-analysis used both direct evidence and indirect evidence to compare all available interventions. They systematically searched electronic databases for randomized trials comparing two or more treatments for ISR. Using a Bayesian approach, 11 treatments were compared in 31 studies with 8,157 patient-years follow-up.

The investigators found that compared with balloon angioplasty, everolimus-eluting stent (hazard ratio [HR] 0.13; 95% credibility interval [CI], 0.048–0.35), paclitaxel-eluting balloon (HR, 0.32; 95% CI, 0.2–0.49), paclitaxel-eluting cutting balloon (HR, 0.054; 95% CI, 0.0017–0.5), paclitaxel-eluting stent (HR, 0.39; 95% CI, 0.24–0.62), and sirolimus-eluting stent (HR, 0.32; 95% CI, 0.18–0.5) are associated with lower target vessel revascularization. Balloon angioplasty is not different from cutting balloon (HR, 0.73; 95% CI, 0.31–1.5), excimer laser (HR, 0.89; 95% CI, 0.29–2.7), rotational atherectomy (HR, 0.96; 95% CI, 0.53–1.7), and vascular brachytherapy (HR, 0.6; 95% CI, 0.35–1.0).

In drug-eluting stent ISR, balloon angioplasty was inferior to everolimus-eluting stent (HR, 0.19; 95% CI, 0.049–0.76), paclitaxel-eluting balloon (HR, 0.43; 95%, 0.18–0.8), paclitaxel-eluting stent (HR, 0.35; 95% CI, 0.13–0.76), and sirolimus-eluting stent (HR, 0.36; 95% CI, 0.11–0.86) for target vessel revascularization. There was no difference between treatments in probable or definitive stent thrombosis.

Additionally, the investigators reported that the results of binary restenosis and target lesion revascularization were similar. Paclitaxel-eluting cutting balloon, everolimus-eluting stent, and paclitaxel-eluting balloon have the highest probability of being in the top three treatments based on low target lesion revascularization, but there was no statistical significant difference between them.

Balloon angioplasty is inferior to all drug-eluting treatments for ISR, including drug-eluting stent ISR. Drug-eluting stent, particularly everolimus-eluting stent, or paclitaxel-eluting cutting balloon and paclitaxel-eluting balloon should be preferred for treating ISR, concluded the investigators in Circulation: Cardiovascular Interventions.