Document Detail

Restenosis after percutaneous angioplasty: the role of vascular inflammation.
Jump to Full Text
MedLine Citation:
PMID:  17319099     Owner:  NLM     Status:  MEDLINE    
Restenosis after endovascular treatment of atherosclerotic lesions in the peripheral, cerebrovascular, and coronary circulation is the major drawback of this minimally invasive technique. Although certain advances have been made during recent years to improve patency rates after percutaneous angioplasty, restenosis remains a challenging clinical problem. Understanding factors that contribute to the pathophysiology of late lumen loss is an effective strategy to improving patients' postangioplasty outcome. Vascular inflammation after balloon angioplasty or stent implantation has been identified as a cornerstone of the restenotic process, and several markers of inflammation have been referred to as potential predictors of outcome. This article reviews recent findings on the issue of inflammation and restenosis after percutaneous angioplasty with special attention given to the role of inflammatory parameters as markers for the restenosis risk in the peripheral vessel area.
Martin Schillinger; Erich Minar
Related Documents :
21459139 - Sophocarpine administration preserves myocardial function from ischemia-reperfusion in ...
7796499 - Assessment of coronary artery distensibility by intravascular ultrasound. application o...
20514329 - Percutaneous recanalization of coronary chronic total occlusions: current devices and s...
14556869 - Intravascular ultrasound-guided directional coronary atherectomy for unprotected left m...
10388599 - Ultrastructural characteristics of myocardial and coronary microvascular lesions in kaw...
10190399 - Outcome of target sites escaping high-grade (>70%) restenosis after percutaneous transl...
7006619 - Comparative study of the effects of penbutolol and propranolol in the treatment of angi...
1086089 - Linear densities in mitochondria of human myocardial cells.
21808849 - Diagnostic value of myocardial radionuclide imaging in patients with multivessel corona...
Publication Detail:
Type:  Journal Article; Review    
Journal Detail:
Title:  Vascular health and risk management     Volume:  1     ISSN:  1176-6344     ISO Abbreviation:  Vasc Health Risk Manag     Publication Date:  2005  
Date Detail:
Created Date:  2007-02-26     Completed Date:  2007-03-16     Revised Date:  2013-06-06    
Medline Journal Info:
Nlm Unique ID:  101273479     Medline TA:  Vasc Health Risk Manag     Country:  New Zealand    
Other Details:
Languages:  eng     Pagination:  73-8     Citation Subset:  IM    
Department of Angiology, University of Vienna Medical School, Vienna, Austria.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Acute-Phase Proteins / metabolism
Angioplasty, Balloon / adverse effects*
Anti-Inflammatory Agents / therapeutic use
Arteritis / blood,  etiology*,  physiopathology*,  prevention & control
Atherosclerosis / blood,  physiopathology,  therapy*
Biological Markers / blood
Constriction, Pathologic / therapy
Genetic Predisposition to Disease
Heme Oxygenase-1 / genetics
Interleukin-6 / genetics
Peripheral Vascular Diseases / blood,  physiopathology,  therapy*
Polymorphism, Genetic
Predictive Value of Tests
Recurrence / prevention & control
Risk Factors
Vascular Patency
Reg. No./Substance:
0/Acute-Phase Proteins; 0/Anti-Inflammatory Agents; 0/Biological Markers; 0/IL6 protein, human; 0/Interleukin-6; EC protein, human; EC Oxygenase-1

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Vasc Health Risk Manag
Journal ID (publisher-id): Vascular Health and Risk Management
ISSN: 1176-6344
ISSN: 1178-2048
Publisher: Dove Medical Press
Article Information
Download PDF
? 2005 Dove Medical Press Limited. All rights reserved
Print publication date: Month: 3 Year: 2005
Volume: 1 Issue: 1
First Page: 73 Last Page: 78
ID: 1993932
PubMed Id: 17319099

Restenosis After Percutaneous Angioplasty: The Role of Vascular Inflammation
Martin Schillinger
Erich Minar
Department of Angiology, University of Vienna Medical SchoolVienna, Austria
Correspondence: Correspondence: Martin Schillinger, Department of Internal Medicine II, Division of Angiology, University of Vienna Medical School, Waehringer Guertel 18?20, A-1090 Vienna, Austria Tel +43 1 40400 4670 Fax +43 1 40400 4665 Email


Percutaneous transluminal angioplasty (PTA) is a minimally invasive revascularization procedure for treatment of atherosclerotic lesions in the peripheral, cerebrovascular, and coronary vessel area. Late clinical failure after primarily successful interventions due to recurrent stenosis (restenosis) occurring in up to 60% of the patients within the first 12 months remains the major drawback of percutaneous angioplasty and limits a widespread application of this minimally invasive technique (Gallino et al 1984; Krepel et al 1985; Maca et al 1996; Minar et al 1998; Cejna et al 2001; Exner et al 2001; Schillinger et al 2001). As competitive surgical approaches yield better long-term results, the indications for endovascular revascularisation are a matter of debate (Diegeler et al 2002). Furthermore, with increasing numbers of procedures performed, late sequelae due to recurrent stenoses and the need for costly reinterventions become more frequent. Understanding the factors that contribute to the pathophysiology of late lumen loss is the foundation to develop effective strategies for improvement of patients' postangioplasty outcome. Endovascular brachytherapy (Minar et al 1998, 2000) and the upcoming drug eluting stents (Sousa et al 2001; Suzuki et al 2001; Morice et al 2002) are suggested to reduce the rate of intermediate term restenosis in the peripheral as well as in the coronary vessel area, but selection criteria for patients who are candidates for these expensive procedures with limited availability are indeterminate. Once identified, reliable predictors of the restenosis risk could facilitate the targeted use of measures for prevention of restenosis and help to save healthcare resources.

Accumulating data indicate that insights gained from the link between inflammation and restenosis can yield predictive and prognostic information of considerable clinical utility. Inflammation in the vessel wall in response to balloon injury or stent implantation initiates hypertrophic neointima formation through vascular smooth muscle cell (VSMC) proliferation and constrictive vascular remodelling (O'Brian and Schwartz 1994; Ross 1999; Orford et al 2000). This process of neointima formation and recurrent lumen narrowing has been referred to as manifestation of an inflammatory wound healing response expressed specifically in vascular tissue (Forrester et al 1991). The present article reviews recent findings on the issue of inflammation and restenosis with special attention to the peripheral vessel area.

Pathophysiology of inflammation and restenosis

Chronic vascular inflammation is involved in the development of restenosis after balloon angioplasty and stent implantation (Forrester et al 1991; Belch et al 1997; Serrano et al 1997; Kamijikkoku et al 1998; Kornowski et al 1998; Tsakiris et al 1999; Yutani et al 1999; Lusis 2000; Cippolone et al 2001; Glass and Witztum 2001; Schillinger et al 2001, Schillinger 2002a; Libby et al 2002). Broadly, restenosis can be considered to be a form of hypertrophic wound healing resulting from an interaction between monocyte-derived macrophages, T cells, and the normal cellular elements of the arterial wall. A triggering event for the vascular inflammatory process is shear stress during balloon inflation or stent implantation and vascular injury, which stimulate the production of proinflammatory molecules and activation of circulating monocytes (Serrano et al 1997). Expression of selectins and adhesion molecules mediate the binding of circulating monocytes and penetration of these cells into the vascular wall (Ross 1999; Lusis 2000; Glass and Witztum 2001; Libby et al 2002). The magnitude of monocyte activation and adherence to the vascular wall was suggested to promote late lumen loss (Pietersma et al 1995; Mickelson et al 1996). The first step in adhesion of inflammatory cells at the dilated or stented segment, the ?rolling? of leucocytes, is mediated by selectins, which bind to carbohydrate ligands on leukocytes. The E-selectin serum level, for example, has been demonstrated to closely correlate with the restenosis risk (Belch et al 1997). The firm adhesion of monocytes and T cells to the arterial wall is then mediated via cell adhesion molecules (CAMs); CAMs have also been shown to be associated with the restenotic process (Kamijikkoku et al 1998; Tsakiris et al 1999). Once adherent to the endothelium, the monocytes penetrate into the intima and through the media to the adventitia (Wilcox et al 2001). Monocyte chemotactic protein-1 (MCP 1) appears responsible for monocyte recruitment and direct transmigration into the vascular wall at the treated lesion, and higher serum levels of this chemokine indicate a higher restenosis risk (Cipollone et al 2001). Once resident in the arterial wall, the blood-derived inflammatory cells participate in and perpetuate a local inflammatory response. Inflammatory molecules as well as shear stress during the endovascular procedure stimulate the immigration of VSMCs from the medial layer of the arterial wall past the internal elastic lamina and into the intimal or subendothelial space. Recruitment and proliferation of myofibroblasts and synthesis of extracellular matrix proteins are key factors of hypertrophic neointima formation and restenosis (Wilcox et al 2001). This phase of lesion progression is markedly influenced by interactions between monocyte/macrophages and T cells, which results in the acquisition of many features of a chronic inflammatory state.

Predictive value of inflammatory markers and acute phase proteins

Acute phase reactants are related to atherosclerosis in the peripheral, coronary, and extracranial brain arteries (Heinrich et al 1995; Tsch?pl et al 1997; Blum et al 1998; Buffon et al 1999; Schillinger et al 2002b, Schillinger 2003a, Schillinger 2003b). These circulating markers of inflammation reflect the activity of the disease associated with accumulation of macrophages and proliferation of endothelial cells and vascular smooth muscle cells (Haverkate et al 1997). The plasma proteins, C-reactive protein (CRP), serum amyloid A (SAA), and fibrinogen are sensitive, specific, and fast reacting markers of acute phase reaction (Pepys and Baltz 1983; Young et al 1991; Ernst 1993) and provide an indirect measure of a cytokine dependent inflammatory process of the arterial wall (Pepys 1995; Kuller et al 1996). Balloon injury and stent implantation in the peripheral vessel area have been demonstrated to induce a vascular inflammatory response at the dilated vessel segment, which is measurable by the postintervention course of serum acute phase parameters like CRP, SAA, or fibrinogen (Schillinger et al 2002c), and the severity of arterial injury during balloon injury or stent placement correlated with increased inflammation (Virmani and Farb 1999).

It is well known that patency rates after percutaneous transluminal angioplasty and stent implantation widely depend on the location of the treated lesion. Endovascular treatment of large elastic arteries like the internal carotid artery and the iliac arteries is associated with a relatively low rate of recurrence (Bosch et al 1997; Tetteroo et al 1998; Dormandy and Rutherford 2000; Ahmadi et al 2001). In contrast, in the muscular conduit arteries of the femoropopliteal segment restenosis after PTA more frequently occurs (Adar et al 1989; Jeans et al 1990; Matsi et al 1994; Dormandy and Rutherford 2000). Thus, it seemed reasonable to speculate that these differences of restenosis rates may be due to differences of the extent of inflammation in response to endovascular treatment. Indeed, it could be shown that stent implantation in the muscular arteries of the femoropopliteal segment was associated with a more extensive vascular inflammatory response than stenting of the elastic iliac or carotid arteries, suggesting that the enhanced inflammatory response after femoropopliteal stenting might contribute to the higher rates of restenosis in this vessel area (Schillinger et al 2002d). Nevertheless, the predictive value of acute phase reactants remained to be demonstrated.

Recently, several studies evaluated the prognostic impact of inflammatory laboratory parameters and the potential clinical relevance to predict the individual's restenosis risk. It was consistently shown that elevated baseline values and postintervention levels of these inflammatory parameters were associated with an increased risk for restenosis after peripheral, coronary, and carotid angioplasty (Tsch?pl et al 1997; Blum et al 1998; Buffon et al 1999; Schillinger et al 2001, Schillinger 2002a, Schillinger 2002b, Schillinger 2003a, Schillinger 2003b). Elevated CRP levels are an indicator of increased cardiovascular risk in healthy individuals as well as in patients with atherosclerosis (Berk et al 1990; Liuzzo et al 1994; Heinrich et al 1995; Kuller et al 1996; Mendall et al 1996; Haverkate et al 1997). Low level chronic inflammatory activity in the vascular tissue is suggested to cause a CRP elevation in patients with atherosclerosis (Mendall et al 1996), reflecting the activity of the disease. Higher peri-procedure CRP values are thus thought to indicate a higher activity of the disease and an increased susceptibility for hypertrophic vascular remodeling and excessive neointima formation after percutaneous angioplasty. However, it remains indeterminate whether acute phase reactants are only indicators of an increased risk for restenosis or causally contribute to its occurrence. One mechanism of a causal role could be the activation of the complement system, local vascular inflammatory reactions, and subsequent tissue damage (Torzewski et al 1998). Furthermore, CRP at concentrations known to predict adverse vascular events decreases nitric oxide synthesis and inhibits angiogenesis (Verma et al 2002); both factors are markedly involved in the pathogenesis of vascular disease.

The crucial question remains, whether acute phase reactants like CRP will be clinically useful to predict the individual's risk for restenosis. Currently, clear cut-off levels of CRP indicating an increased restenosis risk are lacking, and routine application of these inflammatory parameters therefore seems not to be justified.

Inflammatory and antiinflammatory genes: involvement in restenosis?

Recent research has focused on the potential implications of genetic variability on the pathophysiology of vascular disease (Jukema et al 2000; Kastrati et al 2000; Bauters et al 2001; Roguin et al 2001). Traditional risk factors for recurrent lumen narrowing after percutaneous angioplasty ? like local hemodynamics or technical success ? account for only a minor proportion of the restenosis risk, and genetic predisposition seems to markedly influence the individual's susceptibility for this process (Exner et al 2001). In particular, genes encoding for inflammatory or anti-inflammatory proteins are suggested to play a pivotal role in the pathophysiology of lesion recurrence. Several candidate genes have been investigated so far. Briefly, genetic variability may be found in most of the genes encoding for the inflammatory parameters mentioned above: interleukins, selectins, CAMs etc. Variable expression of almost all of these factors may influence the extent of vascular inflammation in response to percutaneous angioplasty, and thus the occurrence of restenosis. However, results of most observational studies demonstrating an association between a genetic characteristic and the restenosis risk have to be interpreted cautiously ? type II errors or false positive findings are likely to occur in small patient series.

Exemplary, two specific gene polymorphisms may be discussed that are potentially involved in the patho-physiology of restenosis in the peripheral vessel area: the heme oxygenase 1 (HO-1) genotype, as an antiinflammatory factor; and the interleukin 6 (IL-6) genotype, as an inflammatory polymorphism. Heme oxygenase-1 (HO-1) is a novel vascular protective factor with potent antiinflammatory and antioxidant effects and the ability to inhibit the proliferation of smooth muscle cells (Maines 1988; Tenhunen et al 1989; Duckers et al 2001; Ishikawa et al 2001; Tulis et al 2001). Development of restenosis in large measure involves these very factors that are inhibited by HO-1: inflammation in the vessel wall, constrictive vascular remodeling, and hypertrophic neointima formation through smooth muscle cell proliferation.

HO-1 is up-regulated by balloon angioplasty. However, humans differ quantitatively in their ability to mount a HO-1 response. There is a length polymorphism in the form of a (GT)n dinucleotide repeat in the 5?-flanking region of the human HO-1 gene that modulates the quantitative level of HO-1 activity in response to a given stimulus (Kimpara et al 1997; Yamada et al 2000). The HO-1 promoter genotype was associated with the postintervention inflammatory response and the occurrence of restenosis after femoropopliteal PTA (Exner et al 2001, Schillinger et al 2002e, Schillinger 2004). Patients with a certain genotype of the HO-1 gene promoter exhibited a lower postintervention inflammatory response and a lower restenosis rate at 6 months compared with non-carriers of this genetic variant. This suggested that a stronger HO-1 response is protective against restenosis. Modulation of the postintervention vascular inflammatory response seemed to be an underlying mechanism of the protective effect of HO-1 up-regulation after balloon angioplasty.

Interleukin 6, on the other hand, represents a key factor in the vascular inflammatory cascade after balloon injury that is directly involved in the regulation of the acute phase response. A functional polymorphism in the IL-6 gene promoter has been demonstrated to modulate the cytokine expression in response to vascular injury (Brull et al 2001). Consistently, this IL-6 promoter polymorphism was associated with the 12 months restenosis risk after femoropopliteal PTA in a larger patient series (Exner et al 2004), indicating a potential involvement of pro-inflammatory genes in the restenotic process. Nevertheless, future research will have to focus on more complex gene-gene and gene-environment interactions, since restenosis likely is a polygenetic process and may not be explained by a single genetic polymorphism.

Potential clinical implications

Some experimental data indicate that modulation or suppression of the inflammatory response after endovascular treatment may exert beneficial effects on outcome. Statins are known to exert potent antiinflammatory properties and have been demonstrated to reduce inflammation and progression of atherosclerosis. In this context, it has been recently demonstrated that a statin (pitavastatin) has the ability to inhibit neointimal hyperplasia after stenting in a procine coronary model mainly through a reduction of inflammatory reactions (Yokoyama 2004). Furthermore, in patients with persistently high CRP levels after successful coronary artery stent implantation, oral immunosuppressive therapy with prednisone resulted in a striking reduction of clinical events and angiographic restenosis rate (Versaci et al 2002). In contrast to these conventional pharmacological approaches, various gene therapeutic approaches also seemed promising. In hypercholesterolemic rabbits, local adenovirus-mediated I kappa B alpha gene transfer had the potential to reduce intimal hyperplasia after stent placement (Breuss et al 2002; Cejna et al 2002). Similarly, pre-treatment with recombinant antibodies against leukocyte P-selectin glycoprotein ligand-1, a key factor of inflammation and activation of platelets, in a porcine coronary stent model reduced neointimal proliferation and in-stent restenosis (Tanguay et al 2004). Another experimentally successful gene-therapeutic approach to inhibit inflammation and reduce restenosis was the recently described inhibition of early growth response factor 1 in hypercholesterolemic rabbits after carotid balloon injury (Ohtani et al 2004).


Evidence from experimental, animal, and clinical studies support the hypothesis that vascular inflammation is a key factor in the restenotic process. The extent of vascular inflammation in response to percutaneous angioplasty predicts the restenosis risk, although currently inflammatory markers are not of clinical utility in this context. Variability in genes encoding for vascular inflammatory and antiinflammatory genes is worth further examination with regard to the pathophysiology of recurrent lumen narrowing.

Adar R,Critchfield GC,Eddy DM. A confidence profile analysis of the results of femoropopliteal percutaneous transluminal angioplasty in the treatment of lower-extremity ischemiaJ Vasc Surg 1989;10:57–67. [pmid: 2526233]
Ahmadi R,Willfort A,Lang W,et al. Carotid artery stenting: effect of learning and intermediate-term morphological outcomeJ Endovasc Ther 2001;8:539–46. [pmid: 11797965]
Bauters C,Lamblin N,Amouyel P. Gene polymorphisms and outcome after coronary angioplastyCurr Interv Cardiol Rep 2001;3:281–6. [pmid: 11696293]
Belch JJ,Shaw JW,Kirk G,et al. The white blood cell adhesion molecule E-selectin predicts restenosis in patients with intermittent claudication undergoing percutaneous transluminal angioplastyCirculation 1997;95:2027–31. [pmid: 9133511]
Berk BC,Weintraub WS,Alexander RW. Elevation of c-reactive protein in ?active? coronary artery diseaseAm J Cardiol 1990;65:168–72. [pmid: 2296885]
Blum A,Kaplan G,Vardinon N,et al. Serum amyloid type A may be a predictor or restenosisClin Cardiol 1998;21:655–8. [pmid: 9755382]
Bosch JL,Hunink MG. Meta-analysis of the results of percutaneous transluminal angioplasty and stent placement for aortailiac occlusive diseaseRadiology 1997;204:87–96. [pmid: 9205227]
Breuss JM,Cejna M,Bergmeister H,et al. Activation of nuclear factor-kappa B significantly contributes to lumen loss in a rabbit iliac artery balloon angioplasty modelCirculation 2002;105:633–8. [pmid: 11827931]
Brull DJ,Montgomery HE,Sanders J,et al. Interleukin-6 gene ?174G>C and ?572G>C promoter polymorphisms are strong predictors of plasma interleukin-6 levels after coronary artery bypass surgeryArterioscler Thromb Vasc Biol 2001;21:1457–63.
Buffon A,Liuzzo G,Biasucci LM,et al. Preprocedural serum levels of C-reactive protein predict early complications and late restenosis after coronary angioplastyJ Am Coll Cardiol 1999;34:1512–21. [pmid: 10551701]
Cejna M,Breuss JM,Bergmeister H,et al. Inhibition of neointimal formation after stent placement with adenovirus-mediated gene transfer of I kappa B alpha in the hypercholesterolemic rabbit model: initial resultsRadiology 2002;223:702–8. [pmid: 12034938]
Cejna M,Thurnher SA,Illiasch H,et al. PTA vs Palmaz stent placement in femoropopliteal artery obstructions: a multicenter prospective randomised studyJ Vasc Interven Radiol 2001;12:23–31.
Cipollone F,Marini M,Fazia M,et al. Elevated circulating levels of monocyte chemoattractant protein-1 in patients with restenosis after coronary angioplastyArterioscler Thromb Vasc Biol 2001;21:327–34. [pmid: 11231910]
Diegeler A,Thiele H,Falk V,et al. Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary arteryN Engl J Med 2002;347:561–6. [pmid: 12192015]
Dormandy JA,Rutherford B. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC)J Vasc Surg 2000;31(1 Pt 2):S1–296. [pmid: 10666287]
Duckers HJ,Boehm M,True AL,et al. Heme oxygenase-1 protects against vascular constriction and proliferationNat Med 2001;7:693–8. [pmid: 11385506]
Ernst E. Fibrinogen as a cardiovascular risk factor: interrelationship with infections and inflammationEur Heart J 1993;14:82–7. [pmid: 8131795]
Exner M,Schillinger M,Minar E,et al. Heme oxygenase-1 microsatellite gene promoter polymorphism is associated with restenosis after percutaneous transluminal angioplastyJ Endovasc Ther 2001;8:433–40. [pmid: 11718398]
Exner M,Schillinger M,Minar E,et al. Interleukin 6 genotype and restenosis after balloon angioplasty: initial observationRadiology 2004;231:839–44. [pmid: 15105457]
Forrester JS,Fishbein M,Helfant R,et al. A paradigm for restenosis based on cell biological clues for the development of new preventive therapiesJ Am Coll Cardiol 1991;17:758–69. [pmid: 1993798]
Gallino A,Mahler F,Probst P,et al. Percutaneous transluminal angioplasty of the arteries of the lower limbs: a 5 year follow-upCirculation 1984;70:619–23. [pmid: 6236912]
Glass CK,Witztum JL. Atherosclerosis: the road aheadCell 2001;104:503–16. [pmid: 11239408]
Haverkate F,Thompson SG,Pyke SDM,et al. Production of C-reactive protein and risk of coronary events in stable and unstable anginaLancet 1997;349:462–6. [pmid: 9040576]
Heinrich J,Schulte H,Sch?nfeld R,et al. Association of variables of coagulation, fibrinolysis and acute-phase with atherosclerosis in coronary and peripheral arteries and those arteries supplying the brainThromb Haemost 1995;73:374–9. [pmid: 7667818]
Ishikawa K,Sugawara D,Wang Xp,et al. Heme oxygenase-1 inhibits atherosclerotic lesion formation in LDL-receptor knockout miceCirc Res 2001;88:506–12. [pmid: 11249874]
Jeans WD,Armstrong S,Cole SE,et al. Fate of patients undergoing transluminal angioplasty for lower-limb ischemiaRadiology 1990;177:559–64. [pmid: 2145608]
Jukema JW,Kastelein JJ. Tailored therapy to fit individual profiles Genetics and coronary artery diseaseAnn N Y Acad Sci 2000;902:17–24. [pmid: 10865822]
Kamijikkoku S,Murohara T,Tayama S,et al. Acute myocardial infarction and increased soluble intercellular adhesion molecule-1: a marker of vascular inflammation and risk of early restenosis?Am Heart J 1998;136:231–6. [pmid: 9704683]
Kastrati A,Dirschinger J,Schomig A. Genetic risk factors and restenosis after percutaneous coronary interventionsHerz 2000;25:34–46. [pmid: 10713908]
Kimpara T,Takeda A,Watanabe K,et al. Microsatellite polymorphism in the human heme oxygenase-1 gene promoter and its application in association studies with Alzheimer and Parkinson diseaseHum Genet 1997;100:145–7. [pmid: 9225984]
Kornowski R,Hong MK,Tio FO,et al. In-stent restenosis: contributions of inflammatory responses and arterial injury to neointimal hyperplasiaJ Am Coll Cardiol 1998;31:224–30. [pmid: 9426044]
Krepel VM,van Andel GJ,van Erp WF,et al. Percutaneous transluminal angioplasty of femoropopliteal artery: initial and long term resultsRadiology 1985;156:325–8. [pmid: 3160061]
Kuller LH,Tracy RP,Shaten J,et al. Relation of C-reactive protein and coronary heart disease in the MRFIT nested case-control studyAm J Epidemiol 1996;144:537–47. [pmid: 8797513]
Libby P,Ridker P,Maseri A. Inflammation and atherosclerosisCirculation 2002;105:1135–43. [pmid: 11877368]
Liuzzo G,Biasucci L,Gallimore JR,et al. The prognostic value of C-reactive protein and serum amyloid A protein in severe unstable anginaN Engl J Med 1994;331:417–24. [pmid: 7880233]
Lusis AJ. AtherosclerosisNature 2000;407:233–41. [pmid: 11001066]
Maca T,Ahmadi R,Derfler K,et al. Elevated lipoprotein(a) and increased incidence of restenosis after femoropopliteal PTA. Rationale for the higher risk of recurrence in females?Atherosclerosis 1996;127:27–34. [pmid: 9006801]
Maines MD. Heme oxygenase: function, multiplicity, regulatory mechanisms and clinical applicationFASEB J 1988;2:2557–68. [pmid: 3290025]
Matsi PJ,Manninen HI,Vanninen RL,et al. Femoropopliteal angioplasty in patients with claudication: primary and secondary patency in 140 limbs with 1?3-year follow-upRadiology 1994;191:727–33. [pmid: 8184053]
Mendall MA,Patel P,Ballam L,et al. C reactive protein and its relation to cardiovascular risk factors: a population based cross sectional studyBMJ 1996;312:1061–5. [pmid: 8616412]
Mickelson JK,Lakkis NM,Villarreal-Levy G,et al. Leukocyte activation with platelet adhesion after coronary angioplasty: a mechanism for recurrent disease?J Am Coll Cardiol 1996;28:345–53. [pmid: 8800108]
Minar E,Pokrajac B,Ahmadi R,et al. Brachytherapy for prophylaxis of restenosis after long-segment femoropopliteal angioplasty: pilot studyRadiology 1998;208:173–9. [pmid: 9646810]
Minar E,Pokrajac B,Maca T,et al. Endovascular brachytherapy for prophylaxis of restenosis after femoropopliteal angioplasty: results of a prospective randomised studyCirculation 2000;102:2694–9. [pmid: 11094034]
Morice MC,Serruys PW,Sousa JE,et al. A randomised comparison of a sirolymus-eluting stent with a standard stent for coronary revascularizationN Engl J Med 2002;346:1773–80. [pmid: 12050336]
O'Brian ER,Schwartz SM. Update of the biology and clinical study of restenosisTrends Cardiovasc Med 1994;4:169–78.
Ohtani K,Egashira K,Usui M,et al. Inhibition of neointimal hyperplasia after balloon injury by cis-element ?decoy? of early growth response gene-1 in hypercholesterolemic rabbitsGene Ther 2004;11:126–32. [pmid: 14712296]
Orford JL,Selwyn AP,Ganz P,et al. The comparative pathobiology of atherosclerosis and restenosisAm J Cardiol 2000;86(Suppl):6H–11H.
Pepys MB. Weatherall DJ,Ledingham JGG,Warrell DAThe acute phase response and C-reactive proteinOxford textbook of medicine, third edition 1995Oxford: Oxford Univ Pr.; :1527–33.
Pepys MB,Baltz ML. Acute phase proteins with special reference to C-reactive protein and related proteins (pentaxins) and serum amyloid A protein (Review)Adv Immunol 1983;34:141–212. [pmid: 6356809]
Pietersma A,Kofflard M,de Wit LE,et al. Late lumen loss after coronary angioplasty is associated with the activation status of circulating phagocytes before treatmentCirculation 1995;91:1320–5. [pmid: 7867168]
Roguin A,Hochberg I,Nikolsky E,et al. Haptoglobin phenotype as a predictor of restenosis after percutaneous transluminal coronary angioplastyAm J Cardiol 2001;87:330–2. [pmid: 11165970]
Ross R. Atherosclerosis ? an inflammatory diseaseN Engl J Med 1999;340:115–26. [pmid: 9887164]
Schillinger M,Exner M,Mlekusch W,et al. Vascular inflammation and percutaneous transluminal of the femoropopliteal artery: association with restenosisRadiology 2002a;225:21–6. [pmid: 12354979]
Schillinger M,Exner M,Mlekusch W,et al. Fibrinogen and restenosis after endovascular treatment of the iliac arteries: a marker of inflammation or coagulation?Thromb Haemost 2002b;87:959–65. [pmid: 12083502]
Schillinger M,Exner M,Mlekusch W,et al. Balloon angioplasty and stent implantation induce a vascular inflammatory reactionJ Endovasc Ther 2002c;9:59–66. [pmid: 11958327]
Schillinger M,Exner M,Mlekusch W,et al. Inflammatory response to stent implantation: differences in femoropopliteal, iliac, and carotid arteriesRadiology 2002d;224:529–35. [pmid: 12147852]
Schillinger M,Exner M,Mlekusch W,et al. Heme oxygenase-1 genotype is a vascular anti-inflammatory factor following balloon angioplastyJ Endovasc Ther 2002e;9:385–94. [pmid: 12222997]
Schillinger M,Exner M,Mlekusch W,et al. Endovascular revascularisation below the knee: 6 months results and predictive value of C-reactive protein levelRadiology 2003a;227:419–25. [pmid: 12649419]
Schillinger M,Exner M,Mlekusch W,et al. Acute phase response after stent implantation in the carotid artery: association with 6 months instent restenosisRadiology 2003b;227:516–21. [pmid: 12649420]
Schillinger M,Exner M,Minar E,et al. Heme oxygenase-1 genotype and restenosis after balloon angioplasty: a novel vascular protective factorJ Am Coll Cardiol 2004;43:950–7. [pmid: 15028349]
Schillinger M,Haumer M,Schlerka G,et al. Restenosis after percutaneous transluminal angioplasty in patients with peripheral artery disease: the role of inflammationJ Endovasc Ther 2001;8:477–83. [pmid: 11718406]
Serrano CV,Ramires JA,Venturinelli M,et al. Coronary angioplasty results in leucocyte and platelet activation with adhesion molecule expression. Evidence of inflammatory responses in coronary angioplastyJ Am Coll Cardiol 1997;29:1276–83. [pmid: 9137224]
Sousa JE,Costa MA,Abizaid AC,et al. Sustained suppression of neointimal proliferation by sirolimus-eluting stents: one year angiographic and intravascular ultrasound follow-upCirculation 2001;104:2007–11. [pmid: 11673337]
Suzuki T,Kopia G,Hayashi S,et al. Stent-based delivery of sirolimus reduces neointimal formation in a procine coronary modelCirculation 2001;104:1188–93. [pmid: 11535578]
Tanguay JF,Geoffroy P,Sirois MG,et al. Prevention of in-stent restenosis via reduction of thrombo-inflammatory reactions with recombinant P-selectin glycoprotein ligand-1Thromb Haemost 2004;91:1186–93. [pmid: 15175806]
Tenhunen R,Marver HS,Schmid R. Microsomal heme oxygenase. Characterization of the enzymeJ Biol Chem 1969;244:6388–94. [pmid: 4390967]
Tetteroo E,van der Graaf Y,Bosch JL,et al. Randomised comparison of primary stent placement versus primary angioplasty followed by selective stent placement in patients with iliac-artery occlusive disease. Dutch Iliac Stent Trial Study groupLancet 1998;351:1153–9. [pmid: 9643685]
Torzewski J,Torzewski M,Bowyer DE,et al. C-reactive protein frequently colocalizes with the terminal complement complex in the intima of early atherosclerotic lesions of human coronary arteriesArterioscler Thromb Vasc Biol 1998;18:1386–92. [pmid: 9743226]
Tsakiris DA,Tschopl M,Jager K,et al. Circulating cell adhesion molecules and endothelial markers before and after transluminal angioplasty in peripheral arterial occlusive diseaseAtherosclerosis 1999;142:193–200. [pmid: 9920521]
Tsch?pl M,Tsakiris DA,Marbet GA,et al. Role of hemostatic risk factors for restenosis in peripheral arterial occlusive disease after transluminal angioplastyArterioscler Thromb Vasc Biol 1997;17:3208–14. [pmid: 9409313]
Tulis DA,Durante W,Peyton KJ,et al. Heme oxygenase-1 attenuates vascular remodeling following balloon injury in rat carotid arteriesAtherosclerosis 2001;155:113–22. [pmid: 11223432]
Verma S,Wang CH,Li SH,et al. A self-fulfilling prophecy: C-reactive protein attenuates nitric oxide production and inhibits angiogenesisCirculation 2002;106:913–19. [pmid: 12186793]
Versaci F,Gaspardone A,Tomai F,et al. Immunosuppressive Therapy for the Prevention of Restenosis after Coronary Artery Stent Implantation (IMPRESS Study)J Am Coll Cardiol 2002;40:1935–42. [pmid: 12475452]
Virmani R,Farb A. Pathology of in-stent restenosisCurr Opin Lipidol 1999;10:499–506. [pmid: 10680043]
Wilcox JN,Okamoto EI,Nakahara KI,et al. Perivascular responses after angioplasty which may contribute to postangioplasty restenosis: a role for circulating myofibroblasts precursors?Ann N Y Acad Sci 2001;947:68–90. [pmid: 11795311]
Yamada N,Yamaya M,Okinaga S,et al. Microsatellite polymorphism in the heme oxygenase-1 gene promoter is associated with susceptibility to emphysemaAm J Hum Genet 2000;66:187–95. [pmid: 10631150]
Yokoyama T,Miyauchi K,Kurata T. Inhibitory efficacy of pitavastatin on the early inflammatory response and neointimal thickening in a porcine coronary after stentingAtherosclerosis 2004;174:253–9. [pmid: 15136055]
Young B,Gleeson M,Cripps AW. C-reactive protein: a critical reviewPathology 1991;23:118–24. [pmid: 1720888]
Yutani C,Ishibashi-Ueda H,Suzuki T,et al. Histologic evidence of foreign body granulation tissue and de novo lesions in patients with coronary stent stenosisCardiology 1999;92:171–7. [pmid: 10754347]

Article Categories:
  • Review

Keywords: percutaneous transluminal angioplasty, restenosis, inflammation.

Previous Document:  Endothelial cell dysfunction and the vascular complications associated with type 2 diabetes: assessi...
Next Document:  Folic acid: a marker of endothelial function in type 2 diabetes?