Hello brownskingirl-ga
In my answer, I will summarise selected papers which I thought might
be of the greatest interest to you. However, if by doing so I have
not covered any specific questions you might have, please put in a
clarification request, so that I can better tailor my answer to your
needs.
First, I will give you a summary of what I found. The numbers I give
refer to the research papers with the information I am quoting. The
papers are all listed at the end, together with a URL to the author’s
abstract of the paper on Medline. Although you will notice links to
the full text of the articles, these are usually available only to
journal subscribers. It is possible to obtain copies from a document
delivery service, but this can cost $20 or more per article. If you
are interested in reading the full articles, it will be worthwhile
seeing whether your library can acquire them for you at no or reduced
cost.
Firstly, it seems that factors which increase the possibility of
restenosis in general are not the same as those which caused the
original atherosclerosis. Most studies have found that out of various
medical conditions, only diabetes and unstable angina are consistently
associated with an increased risk of restenosis (ref. 1). Ref 2
describes a study done specifically in diabetics who had received
coronary stenting. The authors found that the rate of restenosis in
diabetics was 55%, compared to a rate of 20% in non-diabetic patients.
They concluded: “After arterial injury produced by stent placement,
diabetic patients have a significantly greater incidence of restenosis
because of greater late loss at the treatment site. Because elastic
recoil or vasospasm contributes little to stent restenosis, the
increased late loss of minimum lumen diameter in diabetic patients
suggests that they have a greater predisposition to intimal
hyperplasia.” This means that they think there is a greater tendency
in diabetics for the cells making up the wall of the artery in which
the stent is placed to start dividing more rapidly, and some of the
new tissue produced can grow into the interior of the stent. The
thickening is a cellular response to the injury that inevitably occurs
when a stent is inserted. This was confirmed by a study using
intravascular ultrasound, which found that: “the main reason for
increased restenosis in diabetes mellitus was exaggerated intimal
hyperplasia in both stented and nonstented lesions.” (ref 3).
Turning specifically to in-stent restenosis, a study (ref 4) confirmed
that the rate of in-stent restenosis is higher in diabetic than in
non-diabetic patients. However, it also found that the occurrence of
restenosis in diabetics is higher in those who received small stents
(55% occurrence) than in those given large stents (27% occurrence).
The respective rates of occurrence for non-diabetics were 18% and 15%.
Therefore, the size of the blood vessel that is stented is especially
important in determining the likelihood of in-stent restenosis in
diabetics. The longer the stent, the greater the risk of in-stent
restenosis. Tobacco smoking also increases the risk (ref 7). Among
diabetics, there is a greater risk of in-stent restenosis in those who
have microalbuminuria than in those who do not (ref 14).
Microalbuminuria is the presence of small amounts of a protein called
albumin in the urine. It is the first sign of diabetic kidney
disease. You can read more about it on the web site of the National
Kidney Foundation: http://www.kidney.org/general/news/diabkid.cfm
Ref 5 describes a study which found that while PTCA (balloon
angioplasty) is effective in treating in-stent restenosis, because it
pushes the newly grown tissue out of the stent and also expands the
stent, better results are obtained if PTCA is used as an adjunct to
treatment with excimer laser angioplasty. Excimer laser angioplasty
uses near-ultraviolet laser light to destroy the unwanted tissue.
Because this type of laser does not produce heat, it does not damage
surrounding tissue. However, a later study (ref 6) found that
diabetics showed a trend to an increased recurrent restenosis rate,
causing the authors to suggest that excimer laser angioplasty is
probably not a useful way of treating in-stent restenosis in
diabetics. On the other hand, mechanical removal of tissue
(rotational atherectomy) was found to give better results in
diabetics, although not in other patients (ref 9). This same study
found that in patients with in-stent restenosis and with disease
affecting more than one vessel, the best outcomes were obtained with
coronary artery bypass surgery (CABG), regardless of whether they did
or did not have diabetes.
Radiotherapy is another way in which to treat in-stent restenosis.
This involves treating the blood vessel with very localized dose of
radiation. It was found to reduce signficantly the rate of recurrent
in-stent restenosis in diabetics (ref 15). A report of a large trial
in over 250 patients concluded: “adjunctive Ir-192 [iridium 192]
intracoronary radiation therapy reduces recurrent restenosis after
intervention for in-stent restenosis in patients with and without DM.
The relative impact of this treatment is more pronounced in diabetic
patients because it appears to neutralize the added risk of recurrent
restenosis seen in proliferative diabetic lesions.” (ref 16). You can
read more about this on the web site of Deaconess Hospital:
http://www.deaconess.com/lifeqst/winter02/vascular.html
Good results were obtained with a new stainless steel carbon-coated
stent (Carbostent) in a group of patients at high risk of restenosis,
including diabetics (ref 10). Good results were also reported for
another new stainless steel stent (Terumo stent) in a mixed group of
patients including diabetics (ref 13).
A study in patients with non-insulin-dependent diabetes (ref 8) found
that a drug called troglitazone was able to reduce intimal hyperplasia
after coronary stent implantation. It should therefore reduce the
risk of in-stent restenosis. A later study (ref 12) confirmed this
effect of troglitazone in diabetics. It also found that even in
non-diabetics, reduced glucose tolerance is associated with intimal
hyperplasia, and that the amount of hyperplasia is predicted by the
level of insulin in the blood. Another drug, abciximab, was found to
be beneficial in diabetic patients who had undergone stenting. It
reduced the need for follow-up interventions (which would include
treatment of in-stent restenosis) (ref. 11).
References
1. Journal American College Cardiology 1991 May; Vol. 17 (no 6 Suppl
B):2B-13B
Restenosis after coronary angioplasty: an overview.
Califf RM, Fortin DF, Frid DJ, Harlan WR 3rd, Ohman EM, Bengtson JR,
Nelson CL, Tcheng JE, Mark DB, Stack RS.
Department of Medicine, Duke University Medical Center, Durham, North
Carolina 27710.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2016478&dopt=Abstract
2. Ann Intern Med 1993 March, Vol.118 (no 5):344-349
Restenosis after arterial injury caused by coronary stenting in
patients with diabetes mellitus.
Carrozza JP Jr, Kuntz RE, Fishman RF, Baim DS.
Beth Israel Hospital, Boston, Massachusetts.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8430980&dopt=Abstract
3. Circulation 1997 Mar 18;95(6):1366-1369
Increased restenosis in diabetes mellitus after coronary
interventions is due to exaggerated intimal hyperplasia. A serial
intravascular ultrasound study.
Kornowski R, Mintz GS, Kent KM, Pichard AD, Satler LF, Bucher TA, Hong
MK, Popma JJ, Leon MB.
Intravascular Imaging and Cardiac Catheterization Laboratories,
Washington (DC) Hospital Center, USA.
The full text of this paper is available at:
http://circ.ahajournals.org/cgi/content/full/95/6/1366
4. American Heart Journal 1998 Jul;Vol 136 (no 1):150-155
Midterm angiographic outcome of single-vessel intracoronary stent
placement in diabetic versus nondiabetic patients: a matched
comparative study.
Lau KW, Ding ZP, Johan A, Lim YL.
National Heart Center of Singapore, Singapore.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9665232&dopt=Abstract
5. Circulation 1997 Oct 7;96(7):2183-2189
Treatment of in-stent restenosis with excimer laser coronary
angioplasty: mechanisms and results compared with PTCA alone.
Mehran R, Mintz GS, Satler LF, Pichard AD, Kent KM, Bucher TA, Popma
JJ, Leon MB.
Intravascular Ultrasound Imaging and Cardiac Catheterization
Laboratories, Washington Hospital Center, DC, USA.
The full text of this paper is available at:
http://circ.ahajournals.org/cgi/content/full/96/7/2183
6. Journal American College Cardiology 2000 July, Vol. 36 (no.
1):69-74
Six-month clinical and angiographic outcome after successful excimer
laser angioplasty for in-stent restenosis.
Koster R, Kahler J, Terres W, Reimers J, Baldus S, Hartig D, Berger J,
Meinertz T, Hamm CW.
University Hospital Eppendorf, Medical Clinic, Department of
Cardiology, Hamburg, Germany.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10898415&dopt=Abstract
7. American Journal of Cardiology, Aug Vol. 86 (no 3):336-341
Usefulness of stent length in predicting in-stent restenosis (the
MULTI-LINK stent trials).
Kereiakes D, Linnemeier TJ, Baim DS, Kuntz R, O'Shaughnessy C,
Hermiller J, Fink S, Lansky A, Nishimura N, Broderick TM, Popma J.
The Carl and Edith Lindner Center for Research and Education,
Cincinnati, Ohio 45219, USA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10922447&dopt=Abstract
8. Journal American College Cardiology, 2000 Nov, Vol. 36 (no
5):1529-1535
Troglitazone reduces neointimal tissue proliferation after coronary
stent implantation in patients with non-insulin dependent diabetes
mellitus: a serial intravascular ultrasound study.
Takagi T, Akasaka T, Yamamuro A, Honda Y, Hozumi T, Morioka S, Yoshida
K.
Division of Cardiology, Kobe General Hospital, Japan.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11079654&dopt=Abstract
9. Journal American College Cardiology, 2001 June, Vol. 37 (no
7):1877-1882
Percutaneous and surgical interventions for in-stent restenosis:
long-term outcomes and effect of diabetes mellitus.
Moustapha A, Assali AR, Sdringola S, Vaughn WK, Fish RD, Rosales O,
Schroth G, Krajcer Z, Smalling RW, Anderson HV.
University of Texas Medical School at Houston, USA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11401126&dopt=Abstract
10. Catheter Cardiovascular Intervention, 2001 Dec; Vol. 54 (no.
4):420-426
Clinical and angiographic outcomes following elective implantation of
the Carbostent in patients at high risk of restenosis and target
vessel failure.
Antoniucci D, Valenti R, Migliorini A, Moschi G, Trapani M, Bolognese
L, Santoro GM, Cerisano G.
Division of Cardiology, Careggi Hospital, Florence, Italy
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11747173&dopt=Abstract
11. Catheter Cardiovascular Intervention, 2002 March, Vol. 55 (no
3):321-325
Diabetic patients treated with abciximab and intracoronary stenting.
Walton BL, Mumm K, Taniuchi M, Kurz HI, Lasala JM.
Barnes-Jewish Hospital and Washington University, St. Louis, Missouri
63110, USA
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11870935&dopt=Abstract
12. Journal Diabetes Complications 2002 Jan-Feb Vol. 16 (no 1): 50-55
Impact of insulin resistance on neointimal tissue proliferation after
coronary stent implantation. Intravascular ultrasound studies.
Takagi T, Akasaka T, Yamamuro A, Honda Y, Hozumi T, Morioka S, Yoshida
K.
Division of Cardiology, Kobe General Hospital, Minatojima Nakamachi
4-6, Chuo-Ku, Kobe, Japan.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11872367&dopt=Abstract
13. Journal Invasive Cardiology 2002 May; Vol. 14 (no 5):239-242
Early and late clinical and angiographic outcomes following terumo
coronary stent implantation.
Mak KH, Chan CN, Neoh KH, Damras T, Koh TH, Tan HC, Lim TT, Lau KW,
Lim YT, Lim YL.
Director of Cardiovascular Laboratory, National Heart Centre, 17 Third
Hospital Avenue, Singapore, 168752.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11983943&dopt=Abstract
14. Angiology 2002 May-Jun; Vol. 53 (no 3):287-295
Clinical and angiographic outcomes of diabetic patients after coronary
stenting: a comparison of native vessel stent restenosis rates in
different diabetic subgroups.
Heper G, Durmaz T, Murat SN, Ornek E.
Department of Cardiology, SSK Ihtisas Hastanesi, Ankara, Turkey.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12025916&dopt=Abstract
15. Journal American College Cardiology, 2002 Jun, Vol 39 (no
12):1930-1936
The effect of intracoronary radiation for the treatment of recurrent
in-stent restenosis in patients with diabetes mellitus.
Gruberg L, Waksman R, Ajani AE, Kim HS, White RL, Pinnow EE, Satler
LF, Pichard AD, Kent KM, Lindsay J Jr.
Cardiovascular Research Institute, Washington Hospital Center,
Washington, DC 20010, USA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12084590&dopt=Abstract
16 American Journal Cardiology 2002 Aug 1; Vol 90 (no 3):243-247
Effect of catheter-based iridium-192 gamma brachytherapy on the added
risk of restenosis from diabetes mellitus after intervention for
in-stent restenosis (subanalysis of the GAMMA I Randomized Trial).
Moses JW, Moussa I, Leon MB, Teirstein PS, Fish RD, Ellis SG, Nawas D,
Kluck B, Giorgianni JA, Donohoe D, Kuntz RE.
Lenox Hill Heart and Vascular Institute & Cardiovascular Research
Foundation, New York, New York 10021, USA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12127611&dopt=Abstract
Search strategy
Search on Medline Database
(http://www.ncbi.nlm.nih.gov/entrez/query.fcgi ) at PubMed (National
Library of Medicine), using the search terms: restenosis, stent,
diabetes
Additional searches on Google for 1. microalbuminuria, 2.
brachytherapy |
