The interventionalist?s dilemma: innocent intimal hyperplasia or in-stent restenosis?

This editorial refers to Alpha-adrenergic receptor blockade and hyperaemic response in patients with intermediate coronary stenoses by A. De Bruyne et al. on page 2034 and Uutility of the fractional flow reserve in the evaluation of angiographically moderate in-stent by Lopez-Palop et al. on page 2040 .† One of the remaining challenges in interventional cardiology is in-stent restenosis. In-stent restenosis is difficult to treat, often recurs, and may require repeated interventions including bypass surgery and is therefore often frustrating for both the patient and the physician. If in-stent restenosis is severe and the relation with the patient's complaints or proven ischaemia is clear, there will be little discussion about the necessity to use the full armamentarium of the interventionalist to treat the stenosis, including brachytherapy, drug-eluting stents, and ultimately surgery if intervention fails. However, not infrequently patients return to the out-patient clinic weeks to years after stent implantation, with only mild or moderate in-stent restenosis, leaving unanswered the question whether this is a physiological degree of intimal hyperplasia or true restenosis which can be held responsible for complaints and/or ischaemia. In such cases, it is extremely important for the interventionalist to be sure that treatment is really indicated before opening Pandora's Box as outlined above. This is especially true in today's patient population, with often more (or even many) focal lesions or plaques within the coronary tree, often superimposed upon some degree … *Correspondence to: Prof. Nico H.J. Pijls, Department of Cardiology, Catharina Hospital, Michelangelolaan, PO Box 1350, 5602 ZA Eindhoven, The Netherlands. Tel.: +31 40 239 7004; fax: +31 40 244 7885 (E-mail: cathreine{at}wxs.nl).