Contemporary Trends for the Treatment of In-Stent Restenosis in the United States, 2009 to 2024

BACKGROUND: In-stent restenosis (ISR) remains an important cause of repeat revascularization despite advances in drug-eluting stent technology. Contemporary adoption patterns and outcomes of adjunctive plaque-modification strategies for ISR are incompletely characterized. We evaluated national trends and in-hospital outcomes of ISR percutaneous coronary intervention treated with adjunctive plaque-modification devices versus conventional plain old balloon angioplasty. METHODS: All ISR percutaneous coronary intervention procedures in the National Cardiovascular Data Registry CathPCI Registry from July 2009 to June 2024 were analyzed. Adjunctive ISR therapy was defined as use of excimer laser atherectomy, intravascular lithotripsy, cutting/scoring balloon angioplasty, or rotational/orbital atherectomy with or without stent implantation. Conventional plain old balloon angioplasty included balloon angioplasty with or without stent placement and no adjunctive devices. Multivariable logistic regression clustered by operator was used to assess adjusted in-hospital outcomes. RESULTS: Among 1 065 354 ISR admissions (1 182 599 lesions), adjunctive devices were used in 26.5% of cases, increasing from 20.8% in 2018 Q1 to 40.7% by 2024 Q2. Intravascular lithotripsy showed the most rapid adoption, reaching 16.1% of ISR cases within 4 years of US introduction. Adjunctive therapy was associated with higher odds of in-hospital mortality (odds ratio, 1.25 [95% CI, 1.19-1.31]), myocardial infarction (odds ratio, 1.30 [95% CI, 1.24-1.35]), bleeding (odds ratio, 1.29 [95% CI, 1.26-1.33]), and stroke (odds ratio, 1.11 [95% CI, 1.02-1.22]). Recurrent ISR (14.3%) was more often managed with adjunctive therapy (34.2% versus 25.0% for initial ISR) yet had lower absolute complication rates. CONCLUSIONS: ISR remains a major contributor to percutaneous coronary intervention volume. Use of adjunctive plaque-modification devices, especially intravascular lithotripsy, has risen sharply. Adjunctive therapy was associated with higher in-hospital event rates, likely reflecting lesion complexity.