# In-Stent Restenosis Pathophysiology and Risk Factors: A Comprehensive Review

## TL;DR

This paper reviews the causes and risk factors for in-stent restenosis, a recurring issue after stent implantation, and highlights strategies for prevention and treatment.

## Contribution

The paper provides a comprehensive synthesis of current evidence on the biology and risk factors of in-stent restenosis to guide individualized management.

## Key findings

- In-stent restenosis is a heterogeneous process involving neointimal hyperplasia and neoatherosclerosis.
- Risk factors include diabetes, chronic kidney disease, and suboptimal stent expansion.
- Intravascular imaging helps identify specific mechanisms of restenosis for targeted treatment.

## Abstract

In-stent restenosis (ISR) remains a clinically relevant cause of recurrent ischemia and repeat revascularization despite progressive refinements in stent design and implantation technique. Contemporary data indicate that restenosis-related target lesion revascularization (TLR) has declined from bare-metal stent (BMS) to early- and newer-generation drug-eluting stents (DESs), yet ISR continues to accumulate over long-term follow-up and is associated with worse outcomes than PCI for de novo lesions. Mechanistically, ISR is a time-dependent, heterogeneous process dominated early by neointimal hyperplasia—triggered by mechanical endothelial injury, delayed re-endothelialization, inflammation/oxidative stress, vascular smooth muscle cell phenotypic switching, and extracellular matrix deposition—and later by in-stent neoatherosclerosis, which may confer a higher-risk plaque substrate and overlap with thrombotic complications. Clinically, ISR frequently presents as an acute coronary syndrome (ACS) rather than stable symptoms, underscoring the prognostic relevance of prompt recognition and mechanism-informed management. Patient-level risk determinants repeatedly reported across cohorts include diabetes mellitus, chronic kidney disease, dyslipidemia, hypertension, and smoking, while lesion/procedural factors include small vessel caliber, long/complex or bifurcation lesions, multiple stent layers, and suboptimal stent expansion. Intravascular imaging (OCT/IVUS) is central to phenotyping ISR mechanisms (e.g., underexpansion, calcific neoatherosclerosis, stent fracture, homogeneous hyperplasia) and can guide targeted prevention and therapy. This review synthesizes current evidence on ISR biology and risk factors to support risk stratification, preventive strategies, and individualized management.