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Impact of anemia on in-stent restenosis after percutaneous coronary intervention



Anemia is a common risk factor for post-percutaneous coronary intervention (PCI) adverse events; however, data on its association with in-stent restenosis (ISR) is limited.


538 patients who underwent PCI between January 2017 and September 2019 and follow-up angiography 9–12 months after the initial PCI were enrolled in this study. Baseline clinical and procedural characteristics were compared between the ISR and non-ISR groups, and independent predictors of ISR were determined using propensity score matching.


The incidence of anemia was 53.5% in patients with ISR and 19.0% in those without ISR. Univariable logistic regression analyses showed that anemia (OR, 4.283; 95% CI, 1.949–9.410; P < 0.001), diabetes mellitus (OR, 2.588; 95% CI, 1.176–5.696; P = 0.018), chronic kidney disease (OR, 3.058; 95% CI, 1.289–7.252; P = 0.011), multiple stenting (OR, 2.592; 95% CI, 1.205–5.573; P = 0.015), bifurcation lesion (OR, 2.669; 95% CI, 1.236–5.763; P = 0.012), and calcification (OR, 3.529; 95% CI, 1.131–11.014; P = 0.030) were closely associated with ISR. Low-density lipoprotein cholesterol (LDL-c) levels and stent diameter were also significantly linked to ISR, as was anemia (P = 0.009) after propensity score matching.


Anemia is closely associated with post-PCI ISR, and patients with lower hemoglobin levels are at a higher risk of ISR.

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Percutaneous coronary intervention (PCI) has been an effective and widely used treatment for patients with coronary artery disease (CAD) since 1979 [1]. However, despite ongoing improvements on drug-eluting stents (DES), in-stent restenosis (ISR) remains a major complication of PCI, accounting for approximately 5% of all complications [2, 3]. Multiple factors, including inflammatory response, patient-specific and procedure-related risk factors, are involved in the development of ISR [4].

Anemia is associated with a greater rate of cardiovascular events [5, 6], and its prevalence is comparatively high in patients with CAD. Previous studies have highlighted links between anemia and a higher risk of death, major adverse cardiovascular events (MACE), myocardial infarction (MI), and bleeding post PCI [7,8,9,10]. Most recently, an in-hospital hemoglobin drop ≥ 3 g/dL was independently associated with increased 1-year mortality among patients with acute coronary syndrome managed invasively [11].

While studies have demonstrated associations between anemia and fatal adverse events post-PCI, there is yet no data on the relationship between anemia and ISR. In this study, we sought to identify and establish an association between anemia and ISR and determine its independent predictive ability of ISR post-PCI in patients with CAD.

Materials and methods


Our study complied with the principles of the Declaration of Helsinki and was approved by the Ethics Committee of the First Hospital of Jiaxing, Jiaxing, China. Patient inclusion criteria comprised: (1) fulfilling the criteria for PCI; (2) treatment with second-generation DES; (3) agreement to participate in the study. Patient exclusion criteria constituted: (1) dementia or cognitive dysfunction; (2) severe infection or active liver disease; (3) malignancy; (4) severe chronic kidney disease (estimated glomerular filtration rate [eGFR] < 30 ml/min/1.73 m2) or severe anemia (hemoglobin levels < 6 g/dL), (5) coagulation disorders, and (6) lost follow-up.

Per our criteria, 538 CAD patients treated with second-generation DES between January 2017 and September 2019 and follow-up angiography 9–12 months after the initial PCI at our hospital were enrolled upon provision of written informed consent.

The patients’ medical history, pharmacotherapy, angiographic characteristics, and blood biochemistry tests for low-density lipoprotein cholesterol (LDL-c), and triglycerides (TG) were collected. Chronic kidney disease (CKD) was characterized by markers of kidney damage or decreased eGFR persisting for > 3 months [12], coronary calcification was assessed angiographically and defined as apparent densities observed within the artery at the site of stenosis [13], and anemia was distinguished by baseline hemoglobin (Hb) levels < 13 g/dL for men and 12 g/dL for women [14].

Coronary intervention and follow-up assessment

PCI was performed as described previously, and all patient included were treated with second-generation DES. Follow-up angiography was performed 9–12 months after the first PCI. Restenosis was evaluated using the conventional Quantitative Coronary Angiography (QCA) technique. ISR was defined as a luminal narrowing with more than 50% diameter stenosis of a stented coronary segment or within a 5 mm segment proximal or distal to the stent [15].

Statistical analysis

All statistical analyses were conducted using IBM SPSS 22.0. Data for continuous variables are expressed as the mean ± SD and categorical variables as percentages. Continuous variables were analyzed with t-test and categorical variables with χ2-test. A two-tailed P value less than 0.05 was considered statistically significant. Risk factors for ISR were assessed using binary logistic regression analysis, and odds ratio (OR) and 95% confidence interval (CI) were calculated. We employed the propensity score matching model to analyze the impact of covariates on the relationship between anemia and ISR and also scrutinized the receiver operating characteristics (ROC) curve to establish Hb’s accuracy to predict ISR.


General characteristics of the patients with and without ISR

Of the 538 selected patients, 28 (5.2%) occured ISR, and 20 underwent repeat revascularization assisted by intravascular ultrasound (IVUS). Baseline characteristics are summarized in Table 1. Overall, the patients’ average age was 62.2 ± 10.2 years (ranging from 29 to 87 years), and 71.4% of the total were male. The rate of diabetes mellitus, CKD, multiple stenting, and bifurcation lesion was significantly higher in anemia patients with ISR (P values 0.000, 0.001, 0.035 and 0.000, respectively) than in the non-ISR group. In patients without anemia, ISR occurred more in individuals with lower Hb levels (P values 0.011).

Table 1 Baseline and procedual characteristics

Predictors of ISR at follow-up

Predictors of ISR at follow-up were assessed using binary logistic regression analysis. Potentially correlating and clinically important variables were included in the univariate logistic model (Table 2). Diabetes mellitus (OR, 2.588; 95% CI, 1.176–5.696; P = 0.018), anemia (OR, 4.283; 95% CI, 1.949–9.410; P < 0.001), CKD (OR, 3.058; 95% CI, 1.289–7.252; P = 0.011), multiple stenting (OR, 2.592; 95% CI, 1.205–5.573; P = 0.015), bifurcation lesion (OR, 2.669; 95% CI, 1.236–5.763; P = 0.012), and calcification (OR, 3.529; 95% CI, 1.131–11.014; P = 0.030) were predictors of ISR. LDL-c (OR, 1.651; 95% CI, 1.187–2.296; P = 0.003) and stent diameter (OR, 3.413; 95% CI, 1.361–8.547; P = 0.009) were also associated with ISR, and propensity score matching (Table 3) identified anemia as an independent risk factor for ISR (P = 0.009). ROC curve analysis of the diagnostic accuracy of Hb for ISR produced an area under the curve (AUC) of 0.758 (95% CI, 0.675–0.840; P < 0.001) (Fig. 1).

Table 2 Univariable logistic regression analysis for the prediction of ISR
Table 3 Anemia as an independent predictor of ISR after matching on the propensity score
Fig. 1
figure 1

The ROC curve analysis of Hb’s prediction of ISR. ISR, in-stent restenosis; Hb, hemoglobin; ROC, receiver operating characteristic


Although the association between preprocedural anemia and poor outcomes post-PCI in patients with CAD is common, data on the impact of anemia on ISR at follow-up is scant. In this study, we established a strong association between anemia and the occurrence of ISR, which could be used as an independent predictor of ISR at follow-up.

Catakoglu et al. [16] demonstrated that anemia is a crucial risk factor for predicting nonfatal coronary events, including ST-segment elevation MI, non-ST-segment elevation MI, target vessel revascularization (TVR), and target lesion revascularization (TLR), post-PCI, whereas Geng et al. [17] established no statistically significant relationship between low hemoglobin levels and ISR. In our research, after adjusting for confounding factors, we substantiated a strong link between anemia and ISR, indicating that anemic patients were more likely to develop ISR after undergoing PCI.

How ISR operates in patients with anemia who undergo PCI is not well-known but probably multifactorial. The presence of anemia could lead to a decreased oxygen supply, and hypoxia has been identified with vascular cell proliferation and angiogenesis [18]: both are necessary conditions for the development, maintenance, and expansion of neointimal lesions in restenosis [19,20,21]. Compensatory consequences of hypoxia – such as a hyperdynamic state with increased cardiac output, left ventricular hypertrophy, and progressive cardiac enlargement – and a proatherogenic role also contribute to restenosis [22]. Moreover, anemia correlates independently with high platelet reactivity in patients with DES PCI [23], contributing to the development of restenosis [24, 25]. Most recently, a study demonstrated an association between anemia and higher levels of inflammatory markers, such as high sensitive C-reactive protein, fibrinogen, and serum amyloid A, with the authors pointing out that a relationship between anemia and disease outcomes could be caused by underlying inflammation [26]. Because inflammation response is one of the most critical mechanisms for ISR, it is reasonable to infer that anemia could contribute to the progress of ISR. In addition, lower hemoglobin levels are associated with the dysregulation of endothelial cells, causing ISR as well [27, 28].

We also showed in this investigation that higher LDL-c levels, multiple stenting, bifurcation lesion, and smaller stent diameter were linked to post-PCI ISR, which is consistent with previous findings [29,30,31].

Smoking is a risk factor for CAD, but we found no noteworthy relationship between smoking and ISR. Interestingly, previous studies have reported data supporting the theory that smoking is associated with a lower rate of restenosis, a finding that remains controversial [32]. Diabetes mellitus is considered the most consistent clinical parameter that increases the risk of restenosis [33, 34], which matches our findings.

Multiple studies have also explored the impact of CKD on post-PCI ISR, with the end-stage renal disease found to possibly increase the risk of restenosis occurrence [35], and mild or moderate CKD having no bearing on the incidence of ISR post-PCI [36], which is inconsistent with our results too, one in which patients with CKD were more likely to have anemia.

The current guidelines stipulate a 6 to 12-month DAPT with a class I recommendation after PCI [37, 38]. The duration of DAPT depends on the balance between ischemia and bleeding risk. However, both prolonged and shortened usage of DAPT in patients with CAD undergoing PCI notably affect cardiovascular events. A multicenter prospective real-world study revealed that prolonged DAPT with low-dose ticagrelor was effective and safe, with low incidences of MACE, MI, and stroke/transient ischemic attack, and no major bleeding [39]. P2Y12 inhibitor monotherapy after coronary revascularisation has also been assessed in several trials, with one meta-analysis recently establishing that P2Y12 inhibitor monotherapy was associated with a similar risk of death, MI, or stroke and lower risk of major bleeding as DAPT, suggesting that shortening DAPT to 1 to 3 months post-PCI could be effective and safe [40]. In this study, we found no difference in the impact of DAPT on patients in the ISR and non-ISR groups, with patients with anemia more likely to stop using aspirin, partly because they were concerned about bleeding.

For restenosis within DES, drug-coated balloon (DCB) and DES are both approved with a class I recommendation [38]. Bioresorbable vascular scaffolds (BVS) have also been proposed as a treatment for ISR, with one study showing that BVS is effective in the treatment of ISR and has an acceptable target lesion failure rate [41]. However, the 1-year follow-up results of a BIORESOLVE-ISR study revealed that BVS increases the rate of device-oriented cardiovascular events compared to DES but has a similar rate to DCB [42]. In our study, 20 patients underwent repeat revascularization: 19 were treated with DCB and one with DES. But our findings and those reported are not sufficient for a generalized outcome. Therefore more studies must be conducted to determine the long-term outcomes of different procedures on ISR treatment.

Radial artery is the recommended default vascular access for PCI [38, 43]; however, crossover from radial to femoral access is sometimes required. One recently published investigation showed that crossover from radial to femoral access diminished the bleeding benefit offered by the radial access site but did not increase the risk of MACE incidence [44]. The authors also developed a simple risk score – MATRIX score – to predict radial crossover in patients with ACS, which could improve outcomes [45]. For patients with ISR, the initial access site selection remains essential to improving management and outcomes. In our cohort, all procedures completed were transradial; the long-term prognosis needs, therefore, to be investigated further.

Despite its promises, our investigation has several limitations. First, it was retrospective in nature. Second, the sample size was relatively small, the follow-up period was fairly short, and the patients involved were from a single hospital; the results, therefore, do not represent a general scenario. Third, the loss of follow-up and the exclusion of patients who refused to be enrolled in the study might have led to a bias. Fourth, our findings were based on a single measurement of preprocedural Hb levels, with Hb during the follow-up not evaluated. Finally, some covariates, such as smoking and LDL-c, might have changed during the follow-up period, in turn affecting our inferences. As a result, larger prospective trials must be conducted to establish anemia’s potential as an independent predictor of ISR.


Patients with baseline anemia before PCI have a higher incidence of ISR after PCI than their nonanemic counterparts. Anemia could, therefore, be used as a predictor of ISR. Our results have important clinical implications, with the assessment of Hb levels also crucial during periprocedures.

Availability of data and materials

The datasets generated and analyzed during the present study are not publicly available because of the restrictions by the First Hospital of Jiaxing, but are available from the corresponding author on reasonable request.





Body mass index


Chronic kidney disease


Left ventricular ejection fraction


Acute coronary syndrome


Low-density lipoprotein cholesterol




In-stent restenosis


  1. Gruntzig AR, Senning A, Siegenthaler WE. Nonoperative dilatation of coronary-artery stenosis: percutaneous transluminal coronary angioplasty. N Engl J Med. 1979;301(2):61–8.

    Article  CAS  PubMed  Google Scholar 

  2. Cassese S, Byrne RA, Tada T, Pinieck S, Joner M, Ibrahim T, King LA, Fusaro M, Laugwitz KL, Kastrati A. Incidence and predictors of restenosis after coronary stenting in 10 004 patients with surveillance angiography. Heart. 2014;100(2):153–9.

    Article  PubMed  Google Scholar 

  3. Tsai ML, Hsieh MJ, Chen CC, Chang SH, Wang CY, Chen DY, Yang CH, Yeh JK, Ho MY, Hsieh IC. Comparison of 9-month angiographic follow-up and long-term clinical outcomes of biodegradable polymer drug-eluting stents and second-generation durable polymer drug-eluting stents in patients undergoing single coronary artery stenting. Acta Cardiol Sin. 2020;36(2):97–104.

    PubMed  PubMed Central  Google Scholar 

  4. Jukema JW, Verschuren JJ, Ahmed TA, Quax PH. Restenosis after PCI. Part 1: pathophysiology and risk factors. Nat Rev Cardiol. 2011;9(1):53–62.

    Article  PubMed  Google Scholar 

  5. da Silveira AD, Ribeiro RA, Rossini AP, Stella SF, Ritta HA, Stein R, Polanczyk CA. Association of anemia with clinical outcomes in stable coronary artery disease. Coron Artery Dis. 2008;19(1):21–6.

    Article  PubMed  Google Scholar 

  6. Sabatine MS, Morrow DA, Giugliano RP, Burton PB, Murphy SA, McCabe CH, Gibson CM, Braunwald E. Association of hemoglobin levels with clinical outcomes in acute coronary syndromes. Circulation. 2005;111(16):2042–9.

    Article  CAS  PubMed  Google Scholar 

  7. Kwok CS, Tiong D, Pradhan A, Andreou AY, Nolan J, Bertrand OF, Curzen N, Urban P, Myint PK, Zaman AG, et al. Meta-analysis of the prognostic impact of anemia in patients undergoing percutaneous coronary intervention. Am J Cardiol. 2016;118(4):610–20.

    Article  PubMed  Google Scholar 

  8. Wester A, Attar R, Mohammad MA, Andell P, Hofmann R, Jensen J, Szummer K, Erlinge D, Koul S. Impact of baseline anemia in patients with acute coronary syndromes undergoing percutaneous coronary intervention: a prespecified analysis from the validate-swedeheart trial. J Am Heart Assoc. 2019;8(16):e012741.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Lee PC, Kini AS, Ahsan C, Fisher E, Sharma SK. Anemia is an independent predictor of mortality after percutaneous coronary intervention. J Am Coll Cardiol. 2004;44(3):541–6.

    Article  PubMed  Google Scholar 

  10. Nikolsky E, Aymong ED, Halkin A, Grines CL, Cox DA, Garcia E, Mehran R, Tcheng JE, Griffin JJ, Guagliumi G, et al. Impact of anemia in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: analysis from the controlled abciximab and device investigation to lower late angioplasty complications (CADILLAC) trial. J Am Coll Cardiol. 2004;44(3):547–53.

    Article  PubMed  Google Scholar 

  11. Leonardi S, Gragnano F, Carrara G, Gargiulo G, Frigoli E, Vranckx P, Di Maio D, Spedicato V, Monda E, Fimiani L, et al. Prognostic implications of declining hemoglobin content in patients hospitalized with acute coronary syndromes. J Am Coll Cardiol. 2021;77(4):375–88.

    Article  CAS  PubMed  Google Scholar 

  12. Lameire NH, Levin A, Kellum JA, Cheung M, Jadoul M, Winkelmayer WC, Stevens PE, Conference P. Harmonizing acute and chronic kidney disease definition and classification: report of a kidney disease: improving global outcomes (KDIGO) consensus conference. Kidney Int. 2021;100(3):516–26.

    Article  PubMed  Google Scholar 

  13. Ellis SG, Vandormael MG, Cowley MJ, DiSciascio G, Deligonul U, Topol EJ, Bulle TM. Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease. Implications for patient selection. Multivessel angioplasty prognosis study group. Circulation. 1990;82(4):1193–202.

    Article  CAS  PubMed  Google Scholar 

  14. Spirito A, Gragnano F, Corpataux N, Vaisnora L, Galea R, Svab S, Gargiulo G, Siontis GCM, Praz F, Lanz J, et al. Sex-based differences in bleeding risk after percutaneous coronary intervention and implications for the academic research consortium high bleeding risk criteria. J Am Heart Assoc. 2021;10(12):e021965.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Mehran R, Dangas G, Abizaid AS, Mintz GS, Lansky AJ, Satler LF, Pichard AD, Kent KM, Stone GW, Leon MB. Angiographic patterns of in-stent restenosis: classification and implications for long-term outcome. Circulation. 1999;100(18):1872–8.

    Article  CAS  PubMed  Google Scholar 

  16. Catakoglu AB, Aytekin S, Sener M, Kurtoglu H, Celebi H, Demiroglu IC, Aytekin V. Impact of anemia on nonfatal coronary events after percutaneous coronary interventions. Heart Vessels. 2007;22(6):383–8.

    Article  PubMed  Google Scholar 

  17. Geng N, Su G, Wang S, Zou D, Pang W, Sun Y. High red blood cell distribution width is closely associated with in-stent restenosis in patients with unstable angina pectoris. BMC Cardiovasc Disord. 2019;19(1):175.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Humar R, Kiefer FN, Berns H, Resink TJ, Battegay EJ. Hypoxia enhances vascular cell proliferation and angiogenesis in vitro via rapamycin (mTOR)-dependent signaling. FASEB J. 2002;16(8):771–80.

    Article  CAS  PubMed  Google Scholar 

  19. Agema WR, Jukema JW, Pimstone SN, Kastelein JJ. Genetic aspects of restenosis after percutaneous coronary interventions: towards more tailored therapy. Eur Heart J. 2001;22(22):2058–74.

    Article  CAS  PubMed  Google Scholar 

  20. Brasen JH, Kivela A, Roser K, Rissanen TT, Niemi M, Luft FC, Donath K, Yla-Herttuala S. Angiogenesis, vascular endothelial growth factor and platelet-derived growth factor-BB expression, iron deposition, and oxidation-specific epitopes in stented human coronary arteries. Arterioscler Thromb Vasc Biol. 2001;21(11):1720–6.

    Article  CAS  PubMed  Google Scholar 

  21. Hytonen JP, Taavitsainen J, Laitinen JTT, Partanen A, Alitalo K, Leppanen O, Yla-Herttuala S. Local adventitial anti-angiogenic gene therapy reduces growth of vasa-vasorum and in-stent restenosis in WHHL rabbits. J Mol Cell Cardiol. 2018;121:145–54.

    Article  CAS  PubMed  Google Scholar 

  22. Mozos I. Mechanisms linking red blood cell disorders and cardiovascular diseases. Biomed Res Int. 2015;2015:682054.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Giustino G, Kirtane AJ, Baber U, Genereux P, Witzenbichler B, Neumann FJ, Weisz G, Maehara A, Rinaldi MJ, Metzger C, et al. Impact of anemia on platelet reactivity and ischemic and bleeding risk: from the assessment of dual antiplatelet therapy with drug-eluting stents study. Am J Cardiol. 2016;117(12):1877–83.

    Article  CAS  PubMed  Google Scholar 

  24. Lee MS, David EM, Makkar RR, Wilentz JR. Molecular and cellular basis of restenosis after percutaneous coronary intervention: the intertwining roles of platelets, leukocytes, and the coagulation-fibrinolysis system. J Pathol. 2004;203(4):861–70.

    Article  CAS  PubMed  Google Scholar 

  25. Yang A, Pizzulli L, Luderitz B. Mean platelet volume as marker of restenosis after percutaneous transluminal coronary angioplasty in patients with stable and unstable angina pectoris. Thromb Res. 2006;117(4):371–7.

    Article  CAS  PubMed  Google Scholar 

  26. Lanser L, Fuchs D, Scharnagl H, Grammer T, Kleber ME, Marz W, Weiss G, Kurz K. Anemia of chronic disease in patients with cardiovascular disease. Front Cardiovasc Med. 2021;8:666638.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Sonmez A, Yilmaz MI, Saglam M, Kilic S, Eyileten T, Uckaya G, Caglar K, Oguz Y, Vural A, Yenicesu M, et al. The relationship between hemoglobin levels and endothelial functions in diabetes mellitus. Clin J Am Soc Nephrol. 2010;5(1):45–50.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Yang X, Yang Y, Guo J, Meng Y, Li M, Yang P, Liu X, Aung LHH, Yu T, Li Y. Targeting the epigenome in in-stent restenosis: from mechanisms to therapy. Mol Ther Nucleic Acids. 2021;23:1136–60.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Zhao J, Wang X, Wang H, Zhao Y, Fu X. Occurrence and predictive factors of restenosis in coronary heart disease patients underwent sirolimus-eluting stent implantation. Ir J Med Sci. 2020;189:907–15.

    Article  PubMed  Google Scholar 

  30. Roy P, Okabe T, Pinto Slottow TL, Steinberg DH, Smith K, Torguson R, Xue Z, Gevorkian N, Satler LF, Kent KM, et al. Correlates of clinical restenosis following intracoronary implantation of drug-eluting stents. Am J Cardiol. 2007;100(6):965–9.

    Article  PubMed  Google Scholar 

  31. Kastrati A, Dibra A, Mehilli J, Mayer S, Pinieck S, Pache J, Dirschinger J, Schomig A. Predictive factors of restenosis after coronary implantation of sirolimus- or paclitaxel-eluting stents. Circulation. 2006;113(19):2293–300.

    Article  PubMed  Google Scholar 

  32. Cohen DJ, Doucet M, Cutlip DE, Ho KK, Popma JJ, Kuntz RE. Impact of smoking on clinical and angiographic restenosis after percutaneous coronary intervention: another smoker’s paradox? Circulation. 2001;104(7):773–8.

    Article  CAS  PubMed  Google Scholar 

  33. Gilbert J, Raboud J, Zinman B. Meta-analysis of the effect of diabetes on restenosis rates among patients receiving coronary angioplasty stenting. Diabetes Care. 2004;27(4):990–4.

    Article  PubMed  Google Scholar 

  34. Abizaid A, Kornowski R, Mintz GS, Hong MK, Abizaid AS, Mehran R, Pichard AD, Kent KM, Satler LF, Wu H, et al. The influence of diabetes mellitus on acute and late clinical outcomes following coronary stent implantation. J Am Coll Cardiol. 1998;32(3):584–9.

    Article  CAS  PubMed  Google Scholar 

  35. Aoyama Y, Hirayama H, Ishii H, Kobayashi K, Ishikawa K, Takigawa M, Nanasato M, Yoshida Y, Aoyama T, Yoshikawa D, et al. Impact of chronic kidney disease on a re-percutaneous coronary intervention for sirolimus-eluting stent restenosis. Coron Artery Dis. 2012;23(8):528–32.

    Article  PubMed  Google Scholar 

  36. Best PJ, Berger PB, Davis BR, Grines CL, Sadeghi HM, Williams BA, Willerson JT, Granett JR, Holmes DR Jr, Investigators P. Impact of mild or moderate chronic kidney disease on the frequency of restenosis: results from the PRESTO trial. J Am Coll Cardiol. 2004;44(9):1786–91.

    PubMed  Google Scholar 

  37. Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Juni P, Kastrati A, Kolh P, Mauri L, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: the task force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2018;39(3):213–60.

    Article  PubMed  Google Scholar 

  38. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87–165.

    Article  PubMed  Google Scholar 

  39. Cesaro A, Taglialatela V, Gragnano F, Moscarella E, Fimiani F, Conte M, Barletta V, Monda E, Limongelli G, Severino S, et al. Low-dose ticagrelor in patients with high ischemic risk and previous myocardial infarction: a multicenter prospective real-world observational study. J Cardiovasc Pharmacol. 2020;76(2):173–80.

    Article  CAS  PubMed  Google Scholar 

  40. Valgimigli M, Gragnano F, Branca M, Franzone A, Baber U, Jang Y, Kimura T, Hahn JY, Zhao Q, Windecker S, et al. P2Y12 inhibitor monotherapy or dual antiplatelet therapy after coronary revascularisation: individual patient level meta-analysis of randomised controlled trials. BMJ. 2021;373:n1332.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Jamshidi P, Nyffenegger T, Sabti Z, Buset E, Toggweiler S, Kobza R, Cuculi F. A novel approach to treat in-stent restenosis: 6- and 12-month results using the everolimus-eluting bioresorbable vascular scaffold. EuroIntervention. 2016;11(13):1479–86.

    Article  PubMed  Google Scholar 

  42. Moscarella E, Tanaka A, Ielasi A, Cortese B, Coscarelli S, De Angelis MC, Piraino D, Latib A, Grigis G, Bianchi R, et al. Bioresorbable vascular scaffold versus everolimus-eluting stents or drug eluting balloon for the treatment of coronary in-stent restenosis: 1-Year follow-up of a propensity score matching comparison (the BIORESOLVE-ISR Study). Catheter Cardiovasc Interv. 2018;92(4):668–77.

    Article  PubMed  Google Scholar 

  43. Collet JP, Thiele H, Barbato E, Barthelemy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289–367.

    Article  PubMed  Google Scholar 

  44. Gragnano F, Branca M, Frigoli E, Leonardi S, Vranckx P, Di Maio D, Monda E, Fimiani L, Fioretti V, Chianese S, et al. Access-site crossover in patients with acute coronary syndrome undergoing invasive management. JACC Cardiovasc Interv. 2021;14(4):361–73.

    Article  PubMed  Google Scholar 

  45. Gragnano F, Jolly SS, Mehta SR, Branca M, van Klaveren D, Frigoli E, Gargiulo G, Leonardi S, Vranckx P, Di Maio D et al. Prediction of radial crossover in acute coronary syndromes: derivation and validation of the MATRIX score. EuroIntervention. 2021.

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We thank the patients and their families for agreeing to participate in this study. We thank all the staff of the catheterization lab for their registration of patients’ information.


This study was supported by the Key Medicine Disciplines Co-construction Project of Jiaxing Municipal (2019-ss-xxgbx).

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HH: Conceptualization, Methodology; SW: Formal analysis; GT: Supervision; CZ: Investigation; LS: Conceptualization, Writing-Review, and Editing. All authors read and approved the final manuscript.

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Correspondence to Liang Shen.

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The study followed the principles of the Declaration of Helsinki and was approved by the Ethics Committee of the First Hospital of Jiaxing (No. LS-2020-124). All participants in the study signed consent forms after being fully informed of the purpose of the research.

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Hu, H., Wang, S., Tang, G. et al. Impact of anemia on in-stent restenosis after percutaneous coronary intervention. BMC Cardiovasc Disord 21, 548 (2021).

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