Do you still get chest pain after having a stent? Let's talk about In-Stent Restenosis!

Have you had a stent placed for a heart condition? You may have felt a great sense of relief after doing so. Things like chest pain and shortness of breath are gone, and you may have felt like you had a new lease on life. But, what if, after a while, in a few months, that old disease starts to resurface? What if your chest starts to hurt again? What if you have difficulty breathing? Many people worry at this time. They wonder, "Why is this happening even though a stent has been placed?" The answer to that question is the condition we are talking about today, called 'In-Stent Restenosis'.

Simply put, what is In-Stent Restenosis?

To understand this, let's start from the beginning.

Simply put, 'Stenosis' means that something like our blood vessels become blocked or narrowed. When the coronary arteries that supply blood to the heart become blocked due to fatty deposits (we call this Atherosclerosis ) we call it Coronary Artery Disease (CAD) . Angioplasty is a treatment that doctors use to open up this blocked blood vessel again.

In this, a small balloon is inserted into the blocked area and inflated to widen the blood vessel. Then, to prevent the widened area from collapsing and closing again, a small mesh-like tube (this is what we call a stent ) is placed inside the vein. This allows blood flow to resume.

Okay, now you understand. 'Restenosis' is a word made up of the words 're' (again) and 'stenosis' (blockage). It means, to re-block . So, In-Stent Restenosis is when the blood vessel where the stent was placed becomes blocked again, right where the stent was. While this is very frustrating, it is very important to know why this happens.

Why does the vein get blocked again after a stent is placed?

This is not because of a problem with the stent. This is how our body responds. Imagine when you have an injury on your body, a scar forms as it heals, right? That's what's happening here.

A stent is something that comes from outside our body. So the body treats it like a 'wound' and tries to heal it. During this process, a new layer of cells grows over the stent. This is normal. This new layer of cells makes the stent part of the blood vessel wall, smoothing out the blood flow.

However, some people's bodies overreact to this. Then the layer of cells that forms over the stent, called scar tissue, becomes much thicker than expected . Just like moss growing inside a water pipe and clogging the hole in the pipe, this thickened tissue narrows the blood passage again. That's what we call In-Stent Restenosis.

Who is most at risk for this condition?

Although this condition can occur in anyone who has a stent, some people are at higher risk. Check to see if you have these conditions.

A few more things...

Additionally, this risk may increase if the blocked blood vessel is very small or if the blockage is very long . Also, if the vessel is widened with a balloon without a stent (Balloon Angioplasty), the risk of re-blockage is even higher.

What are the symptoms of this?

One of the biggest challenges here is that most people with In-Stent Restenosis do not experience any symptoms . You may not feel anything until the artery is quite narrowed. That's why it's important to go for regular check-ups as directed by your doctor after having a stent.

However, some people develop symptoms that are very similar to the symptoms of coronary artery disease (CAD) that you had before you had the stent.

• Chest pain or discomfort (Angina): A feeling of tightness or constriction in the chest. This may be worse when you are exercising or climbing stairs.
• Shortness of breath: Difficulty breathing even with mild exertion.
• Feeling unusually tired: Feeling so tired that you can't do things that you used to do easily.
• Shoulder or arm pain: Chest pain accompanied by pain radiating to the left shoulder or arm.
• Symptoms such as dizziness, sweating, and nausea may also occur.

How do I find out if this is available?

When you tell us about your symptoms, the doctor will suggest several tests to confirm it.

• Exercise Stress Test (Treadmill Test): You are made to walk or run on a treadmill and an ECG is used to monitor how your heart works when you are stressed.
• Cardiac Catheterization (Angiogram): This is the most definitive test. Just like with stent placement, a small tube is passed through a blood vessel into the heart, a special dye is injected, and an X-ray is taken to see if there is any blockage inside the stent.
• Other tests: Sometimes, scanning techniques such as Intravascular Ultrasound (IVUS) can be used to look inside the blood vessel and accurately measure the extent of the blockage.

How is it treated?

The doctor will determine the best treatment based on the extent of the blockage and your condition.

Is there no way to prevent this?

Here's the best news. Yes, this is now largely preventable.

The reason for this is a new type of stent called Drug-Eluting Stents (DES) . These are not just metal mesh. These stents contain a special drug that controls the formation of that scar tissue we talked about. After the stent is inserted into the body, this drug is gradually released, stopping the cells from growing unnecessarily.

Compared to older bare metal stents, the risk of in-stent restenosis is very low when these drug-eluting stents are used. Even in Sri Lanka today, this new type of stent is most often used.

However, there are some things you need to do on your part.

• Take your medication as prescribed: Take the medication prescribed by your doctor, especially those that prevent blood clotting (e.g., Aspirin, Clopidogrel), exactly as prescribed, without missing a single day.
• Change your lifestyle: If you smoke, stop immediately . Control your cholesterol, diabetes, and high blood pressure. Eat a healthy diet that is low in oil, salt, and sugar, and high in fruits and vegetables. Exercise as directed by your doctor.