In-stent Restenosis — EECC MCQ

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ModerateCoronary Artery DiseaseIn-stent RestenosisEECC

A 64-year-old man who had a DES implanted to the mid-LAD 18 months ago presents with recurrent stable angina. Angiography shows a 75% stenosis within the stented segment with a smooth, concentric appearance. What is the most likely mechanism?

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Correct answer: A — Neointimal hyperplasia causing in-stent restenosis

In-stent restenosis (ISR) in DES typically occurs within the first 12-24 months and is predominantly caused by neointimal hyperplasia — smooth muscle cell proliferation within the stent. It presents with gradual recurrence of angina (unlike stent thrombosis which is acute). The smooth, concentric appearance is characteristic of neointimal proliferation. Neoatherosclerosis (development of atherosclerotic plaque within the neointima) is a cause of very late ISR (>3 years). Treatment options include drug-coated balloon angioplasty (preferred for DES ISR), repeat DES implantation, or CABG if diffuse. OCT/IVUS helps characterise the mechanism.

Reference: ESC (2024): Guidelines for the Management of Chronic Coronary Syndromes