{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T14:14:49Z","timestamp":1793369689332,"version":"4.5.0"},"reference-count":135,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,2,9]],"date-time":"2026-02-09T00:00:00Z","timestamp":1770595200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100007700","name":"Carol Davila University of Medicine and Pharmacy","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100007700","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>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\u2014triggered by mechanical endothelial injury, delayed re-endothelialization, inflammation\/oxidative stress, vascular smooth muscle cell phenotypic switching, and extracellular matrix deposition\u2014and 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.<\/jats:p>","DOI":"10.3390\/medicina62020345","type":"journal-article","created":{"date-parts":[[2026,2,9]],"date-time":"2026-02-09T10:45:31Z","timestamp":1770633931000},"page":"345","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["In-Stent Restenosis Pathophysiology and Risk Factors: A Comprehensive Review"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6122-7781","authenticated-orcid":false,"given":"Alice Elena","family":"Munteanu","sequence":"first","affiliation":[{"name":"Department of Cardiology, \u2018Carol Davila\u2019 Central Military Emergency University Hospital, 010825 Bucharest, Romania"},{"name":"Department of Medical-Surgical and Prophylactical Disciplines, Faculty of Medicine, \u2018Titu Maiorescu\u2019 University, 031593 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandru Andrei","family":"Badea","sequence":"additional","affiliation":[{"name":"Doctoral School, Faculty of Medicine, \u201cCarol Davila\u201d University of Medicine and Pharmacy, 050474 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-6395-3389","authenticated-orcid":false,"given":"Alexandru Mihai","family":"Popescu","sequence":"additional","affiliation":[{"name":"Doctoral School, Faculty of Medicine, \u201cCarol Davila\u201d University of Medicine and Pharmacy, 050474 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Florentina Cristina","family":"Ple\u0219a","sequence":"additional","affiliation":[{"name":"Department No. 6\u2014Clinical Neurosciences, \u2018Carol Davila\u2019 University of Medicine and Pharmacy, 050474 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Silviu Marcel","family":"Stanciu","sequence":"additional","affiliation":[{"name":"Department of Cardiology, \u2018Carol Davila\u2019 Central Military Emergency University Hospital, 010825 Bucharest, Romania"},{"name":"Department No. 5\u2014Internal Medicine, \u2018Carol Davila\u2019 University of Medicine and Pharmacy, 050474 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,9]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"850","DOI":"10.5603\/CJ.a2021.0042","article-title":"Post-percutaneous coronary intervention angina: From physiopathological mechanisms to individualized treatment","volume":"29","author":"Rosano","year":"2022","journal-title":"Cardiol. 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