Restenosis in coronary bare metal stents. Importance of time to follow-up: A comparison of coronary angiograms 6 months and 4 years after implantation (original) (raw)
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Restenosis after coronary placement of various stent types
The American Journal of Cardiology, 2001
Coronary stent implantation is being performed in an increasing number of patients with a wide spectrum of clinical and lesion characteristics. A variety of stent designs are now available and continuous efforts are being made to improve the stent placement procedure. The objective of this study was to perform a comprehensive analysis of the relation between clinical, lesion, and procedural factors, and restenosis after intracoronary stenting in a large and unselected population of patients. A consecutive series of 4,510 patients with coronary stent placement was analyzed. Exclusion criteria were only a failed procedure and an adverse outcome within the first month after the intervention. Follow-up angiography was performed in 80% of patients at 6 months. Clinical, lesion, and procedural data from all 3,370 patients (4,229 stented lesions) with follow-up angiography were analyzed in a logistic regression model for restenosis (>50% diameter stenosis). Clinical factors contributed to the predictive power of the model much less than lesion and procedural factors. The strongest risk factor for restenosis was a small vessel size, with a 79% increase in the risk for a vessel of 2.7 mm versus a vessel of 3.4 mm in diameter. Stent design was the second strongest factor; the incidence of restenosis ranged from 20.0% to 50.3% depending on the stent type implanted. In conclusion, this study demonstrates the predominant role of lesion and procedural factors in determining the occurrence of restenosis after coronary stent placement. Among these factors, stent design appears to play a particularly important role in the hyperplastic response of the vessel wall.
Journal of the American College of Cardiology, 2015
background: The role of residual atherosclerotic plaque located behind the stent (PBS) is still poorly understood. We examined the natural history of PBS and its impact on subsequent neointimal hyperplasia (NIH) after implantation of bare-metal stents (BMS) compared to first-generation drug-eluted stents (DES). methods: 3D coronary reconstruction by angiography and intravascular ultrasound were performed after intervention and at 6-to10-month follow-up in 157 Japanese patients treated with BMS (n=89) and DES (n=99; sirolimus-eluting stents [SES], 31 and paclitaxel-eluting stents [PES], 68) included in the PREDICTION Study. Each reconstructed stented coronary artery was divided into consecutive 1.5-mm segments. External elastic lamina, lumen, stent, PBS, and NIH areas were measured for each segment. Due to the very low rate of events in our population we used significant NIH (defined as NIH area >50% of stent area) as a binary anatomic outcome. results: There was a significant decrease in PBS (-7.2%; IQR-19.3 to 5.2%, p<0.001) and vessel (-1.7%; IQR-10.0 to 6.0%, p<0.001) areas after BMS and a respective significant increase in both areas after DES implantation (6.1%; IQR-5.7 to 20.5%; p<0.001 and 4.1%; IQR-3.6 to 13.4%, p<0.001, respectively). The decrease in PBS area significantly predicted neointimal area at follow-up after controlling for baseline lumen and PBS areas in BMS (β 0.15; 95% CI 0.10 to 0.20, p<0.001), SES (β 0.03; 95% CI 0.02 to 0.04, p<0.001), and PES (β 0.18; 95% CI 0.12 to 0.24, p<0.001). Multivariate analysis revealed that the decrease in PBS area was the most powerful predictor of significant NIH in BMS (OR 1.13; 95% CI 1.02 to 1.26, p=0.017). Conclusion: PBS decreases after BMS implantation and associates with constrictive remodeling, while it increases after DES implantation and associates with expansive remodeling. Reduction in PBS over time is significantly associated with more severe NIH in both stent types. These findings raise the possibility of a communication between the lesion within the stent and the underlying native atherosclerotic plaque, and may have important implications regarding the pathobiology of in-stent restenosis and late stent thrombosis.
Coronary stents and vascular response to implantation: literature review
Pragmatic and Observational Research, 2017
Drug-eluting stents (DESs) have minimized the limitations of bare-metal stents (BMSs) after percutaneous coronary interventions. Nevertheless, serious concerns remain about possible late complications of stenting, such as stent thrombosis (ST) and in-stent restenosis (ISR), although the introduction of second-generation DESs seems to have softened the phenomenon, compared to the first-generation ones. ST is a potentially catastrophic event, which has been markedly reduced by optimization of stent implantation, novel stent designs, and dual antiplatelet therapy. The exact mechanism to explain its occurrence is under investigation, and, realistically, multiple factors are responsible. ISR of BMSs has been previously considered as a stable condition with an early peak (at 6 months) of intimal hyperplasia, followed by a regression period beyond 1 year. On the contrary, both clinical and histologic studies of DESs have demonstrated evidence of continuous neointimal growth during long-term follow-up, named "late catch-up" phenomenon. The acknowledgment that ISR is a relatively benign clinical condition has been recently challenged by evidences which reported that patients with ISR can experience acute coronary syndromes. Intracoronary imaging is an invasive technology that allows identifying features of atherosclerotic plaque of stent implanted and of vascular healing after stenting; it is often used to complete diagnostic coronary angiography and to drive interventional procedures. Intracoronary optical coherence tomography is currently considered a state-of-the-art imaging technique; it provides, compared to intravascular ultrasound, better resolution (at least >10 times), allowing the detailed characterization of the superficial structure of the vessel wall. Imaging studies "in vivo," in agreement with histological findings, suggest that chronic inflammation and/or endothelial dysfunction may induce late de novo "neoatherosclerosis" inside both BMSs and DESs. So, neoatherosclerosis has become the prime suspect in the pathogenesis of late stent failure.
Histopathology of Clinical Coronary Restenosis in Drug-Eluting Versus Bare Metal Stents
The American Journal of Cardiology, 2009
To characterize in-stent restenosis after the implantation of sirolimus-eluting stents (SES), paclitaxel-eluting stents (PES), tacrolimus-eluting stents (TES), and zotarolimus-eluting stents (ZES), 25 patients treated with drug-eluting stents (DES; 9 PES, 10 SES, 4 TES, and 2 ZES) and 19 with bare-metal stents (BMS) underwent directional coronary atherectomy for in-stent restenosis 4 to 36 months after implantation. Restenosis after DES implantation was more frequently focal and associated with smaller specimens compared to that after BMS implantation. Light and confocal microscopy were used. Histologic features were similar in DES and BMS. In-stent restenotic lesions were composed mainly of neointima containing proteoglycan-rich smooth muscle cells and fibrolipidic regions. Small inflammatory infiltrates were observed, mostly in patients with unstable angina; CD18and/or CD3 ؉ cells were detected in patients with BMS and DES. Different smooth muscle cell phenotypes were observed: synthetic was more frequent with BMS and PES, intermediate with ZES, contractile or intermediate with SES, and contractile with TES. The mean proliferation index was low and comparable among stent types; cyclins B1 and D1 were expressed in all DES. In conclusion, intra-DES and intra-BMS restenotic tissue was composed mainly of smooth muscle cells with different phenotypes, proliferating at a low rate. The different smooth muscle cell phenotypes within the stent types might suggest different mechanisms of restenosis.
Archivos de cardiología de México
In-stent restenosis (ISR) has an incidence between 20% and 30% using bare metal stents. ISR late regression phenomenon (ISRLR) has been previously described, but clinical variables related with this phenomenon remain unclear. The aim of the study was to identify the variables related with ISRLR. We identified from our data base 30 patients between November 1995 and September 2002 that fulfilled the following criteria: 1) Documented ISR at follow-up angiography (CA-1); 2) treated medically; and 3) Referred for a second follow-up angiography (CA-2). at least 3 months after CA-1. ISRLR was defined as a > 0.2 mm increase in MLD between CA-1 and CA-2, calculated as the 2-fold of our inter-observer variability. ISR late progression was defined as a > 0.2 mm decrease in minimum lumen diameter (MLD) between CA-1 and CA-2. At the time of CA-2 only 2 patients (6.7%) had symptoms related with the previously stented vessel. We found a mean MLD of 1.03+/-0.34 mm and 1.54+/-0.48 mm at CA-1 ...
Impact of stent diameter and length on in-stent restenosis after bare metal stent implantation
2017
The stents utilisation in the interventional treatment of coronary lesions is associated with a reduced risk of peri and post-procedural complications rate compared with balloon angioplasty. The knowledge of the technical risk factors for in-stent restenosis can guide the patient selection or the choice of stent type. The aim of this study was to identify the "bare metal" stents characteristics associated with high risk of angiographic recurrence. Patients with in-stent restenosis have smaller stent diameter and greater stent length comparing to control group. The clinical and paraclinical follow-up of patients with these risk factors should be more frequent.
Neointimal Tissue Proliferation After Coronary Stent Implantation Without Predilatation
Revista Espanola De Cardiologia, 2005
IVUS) studies in conventional stent angioplasty with predilatation have demonstrated that late luminal narrowing is caused by neointimal proliferation. In the present study, we analyzed the degree and distribution of in-stent neointimal proliferation after direct stent implantation and aimed to identify variables that predict a proliferative response.
Restenosis is not associated with stent length in a pig model of coronary stent implantation
Cardiology journal, 2008
The aim of this study was to determine if stent length is by itself a risk factor for intimal proliferation and restenosis. Long lesions represent an independent risk factor for restenosis after coronary stent implantation. A longer stented segment might result in a higher probability of restenosis. Twenty-two 7-month-old male farm pigs underwent implantation of two steel stents, one short (8 mm length) and one long (16 mm length), in the right coronary artery. The pigs were sacrificed 28 days after stent implantation and histomorphometric analysis of the coronary arteries was performed for neointimal area proliferation and area stenosis evaluation. Seventeen short stents and 19 long stents were finally implanted. There were no differences in neointimal proliferation (1.84 +/- 0.64 mm2 vs. 1.81 +/- 0.94 mm2, p = 0.84), area stenosis (40 +/- 9% vs. 41 +/- 19%, p = 0.86) and lumen area (2.96 +/- 1.30 mm2 vs. 2.51 +/- +/- 1.18 mm2, p = 0.21) between the short stent group and the long s...