Predictors for Neoatherosclerosis

Coronary stent failure: role of a blended approach with drug-coated balloons for complex lesions

The management of coronary artery disease by means of percutaneous approach have been focused initially to overcome the recoil and acute occlusion after vessel ballooning; therefore, to develop and improve metallic stent platforms, and later drug-eluting technologies. Contemporarily, the necessity emerged to optimize interventional procedures using functional physiologic tests and intravascular imaging guidance, but still stent failures, especially in the complex lesion setting, continue to be not negligible. This comprehensive review is focused on the technology of drug-coated balloons as a tool to treat coronary artery disease without the need for metal implantation but still eluting antirestenotic drugs such as paclitaxel or sirolimus. We delve into these technologies, the drugs, the technical aspects of the deployment and the most updated evidence also proposing a dedicated interventional algorithm. There is solid data to support the use of drug-coated balloons in patients with in-stent restenosis and de-novo small coronary artery disease but also new evidence with promising results from recent studies indicate the feasibility of this approach in complex coronary interventions, bifurcation lesions and larger coronary vessels. In this state-of-the-art review, we also propose a blended approach based on the combination of drug-eluting stents and drug-coated balloons, keeping in mind the necessity to reduce the total stent length in order to reduce the long-term risk of complications.

Impact of baseline yellow plaque assessed by coronary angioscopy on vascular response after stent implantation

BACKGROUND

The relationship between baseline yellow plaque (YP) and vascular response after stent implantation has not been fully investigated.

METHODS

This was a sub-analysis of the Collaboration-1 study (multicenter, retrospective, observational study). A total of 88 lesions from 80 patients with chronic coronary syndrome who underwent percutaneous coronary intervention were analyzed. Optical coherence tomography (OCT) and coronary angioscopy (CAS) were serially performed immediately and 11 months after stent implantation. YP was defined as the stented segment with yellow or intensive yellow color assessed by CAS. Neoatherosclerosis was defined as a lipid or calcified neointima assessed by OCT. OCT and CAS findings at 11 months were compared between lesions with baseline YP (YP group) and lesions without baseline YP (Non-YP group).

RESULTS

Baseline YP was detected in 37 lesions (42 %). OCT findings at 11 months showed that the incidence of neoatherosclerosis was significantly higher in the YP group (11 % versus 0 %, p = 0.028) and mean neointimal thickness tended to be lower (104 ± 43 μm versus 120 ± 48 μm, p = 0.098). CAS findings at 11 months demonstrated that the dominant and minimum neointimal coverage grades were significantly lower (p = 0.049 and P = 0.026) and maximum yellow color grade was significantly higher (p < 0.001) in the YP group.

CONCLUSIONS

Baseline YP affected the incidence of neoatherosclerosis as well as poor neointimal coverage at 11 months after stent implantation.

Procedural and clinical impact of intravascular lithotripsy for the treatment of peri-stent calcification

BACKGROUND

Use of intravascular lithotripsy (IVL) for treating peri-stent calcification is increasing. However, this indication remains 'off-label'. We aimed to investigate the efficacy and clinical outcomes of in-stent IVL.

METHODS

Patients from five European centers who underwent in-stent IVL were included between 2019 and 2023. Demographic, clinical, procedural and follow-up data were collected from electronic hospital records. Angiographic and intracoronary imaging (ICI) data were analyzed in a centralized core-laboratory.

RESULTS

Of 101 patients (71.2 ± 9.2 years), 56(55 %) received in-stent IVL for late stent failure (median 109 days post-PCI) due to calcific neoatherosclerosis or extra-stent calcification(late-IVL), while 45(45 %) underwent bail-out IVL due to stent infraexpasion (immediate-IVL). Both late-IVL and immediate-IVL significantly improved angiographic %diameter stenosis (73.7[59.6-89.8]% to 16.4 [10.4-26.9]%;p < 0.0001 and 28.6[22.5-43.3]% to 14.1[10.3-29.4]%;p < 0.0001, and minimum lumen area (MLA) (3.4 ± 1.2 to 8.6 ± 2.5 mm2;p < 0.002 and 5.4 ± 1.9 to 7.3 ± 1.9;p < 0.0001).Device(98 %) and procedural success(80 %) were high. MACE rates in-hospital (2 %), 30-days (3 %),6-months(5 %) and 1-year(7 %) were low and comparable in both groups. Acute diameter gain was lower in immediate-IVL (2.1 ± 0.7 mm vs. 0.5 ± 0.4 mm;p < 0.0001). This, however, was explained by significant differences in pre-IVL angiographic and ICI parameters (%diameter stenosis 73.7[59.6-89.8] vs. 28.6[22.5-43.3]%; p < 0.0001 and MLA (3.4 ± 1.2 vs 5.4 ± 1.9 mm2; p < 0.0001), whereas post-IVL percentage diameter stenosis (16.4(10.4-26.9) vs. 14.1(10.3-29.4);p = 0.914) and MLA (8.6 ± 2.5vs. 7.4 ± 1.9 mm2;p = 0.064) in late- and immediate-IVL were comparable.

CONCLUSIONS

IVL in-stent due to peri-stent calcification is an effective strategy, both late and immediately after stent implantation. Overall, MACE rates at short- and mid-term were low and comparable in both groups, although clinical findings should be taken with caution.

Association of the monocytes to high-density lipoprotein cholesterol ratio with in-stent neoatherosclerosis and plaque vulnerability: An optical coherence tomography study

BACKGROUND

Monocyte-to-high-density lipoprotein cholesterol ratio (MHR) is an independent predictor of atherosclerosis and in-stent restenosis (ISR). However, the association between MHR and the incidence of in-stent neoatherosclerosis (ISNA) remains to be validated.

METHODS

This study included 216 patients with acute coronary syndrome who had 220 ISR lesions and had undergone optical coherence tomography (OCT). All eligible patients were divided into three groups according to their MHR tertile level. OCT characteristics were comparatively analyzed between groups of different MHR levels, and univariate and multivariate logistic regression analyses were constructed to assess correlations between MHR level and ISNA as well as in-stent thin-cap fibroatheroma (TCFA). A receiver operating characteristic curve was used to determine the optimal MHR thresholds for predicting ISNA and in-stent TCFA.

RESULTS

The incidence of ISNA (70.3% vs. 61.1% vs. 20.3%, P < 0.001) and in-stent TCFA (40.5% vs. 31.9% vs. 6.8%, P < 0.001) was the highest in the third tertile, followed by the second and first tertiles, respectively. Multivariate analysis revealed that MHR was independently associated with ISNA (odds ratio [OR], 7.212; 95% confidence interval [CI], 1.287-40.416; P = 0.025) and in-stent TCFA (OR, 5.610; 95% CI, 1.743-18.051; P = 0.004) after adjusting for other clinical factors. The area under the curve was 0.745 (95% CI, 0.678-0.811; P < 0.001) for the prediction of ISNA and 0.718 (95% CI, 0.637-0.778; P < 0.001) for the prediction of in-stent TCFA.

CONCLUSION

MHR levels are an independent risk factor for ISNA.

Cardiac Optical Coherence Tomography: History, Current Status, and Perspective

For more than 2 decades since the first imaging procedure was performed in a living patient, intravascular optical coherence tomography (OCT), with its unprecedented image resolution, has made significant contributions to cardiovascular medicine in the realms of vascular biology research and percutaneous coronary intervention. OCT has contributed to a better understanding of vascular biology by providing insights into the pathobiology of atherosclerosis, including plaque phenotypes and the underlying mechanisms of acute coronary syndromes such as plaque erosion, neoatherosclerosis, stent thrombosis, and myocardial infarction with nonobstructive coronary arteries. Moreover, OCT has been used as an adjunctive imaging tool to angiography for the guidance of percutaneous coronary intervention procedures to optimize outcomes. However, broader application of OCT has faced challenges, including subjective interpretation of the images and insufficient clinical outcome data. Future developments including artificial intelligence-assisted interpretation, multimodality catheters, and micro-OCT, as well as large prospective outcome studies could broaden the impact of OCT on cardiovascular medicine.

Association of Endothelial Nitric Oxide Synthase and Angiotensin-Converting Enzyme Genes Polymorphism With In-Sent Restenosis of Bare Metal Stents vs Drug-Eluting Stents in Egyptians

Despite its unequivocal superiority compared with balloon angioplasty, coronary stenting did not abolish restenosis. We aimed to evaluate the associations between a common single nucleotide polymorphism occurring in endothelial nitric oxide synthase (eNOS) and angiotensin-converting enzyme (ACE) genes and the risk of in-stent restenosis (ISR) of bare metal stents vs drug-eluting stents (BMS vs DES) implanted in Egyptian patients. Two hundred patients who had coronary stenting were divided into group I (n = 98) who received a BMS and group II (n = 102) who received a DES. eNOS and ACE genes polymorphism were analyzed by polymerase chain reaction (PCR). We found that the GA and AA genotypes of the eNOS gene were associated with the ISR with both BMS and DES. However, the ACE gene was not associated with ISR. We concluded that eNOS gene polymorphism is associated with ISR. Hypertension, stent length, and AA genotype of the eNOS gene were found to be independent predictors of the occurrence of ISR after both BMS and DES use.

Association of LDL-C level with neoatherosclerosis and plaque vulnerability in patients with late restenosis: an optical coherence tomography study

Neoatherosclerosis (NA) is a significant contributor to late stent failure; however, predictors of late in-stent restenosis (ISR) with NA have not been systematically reported. This study aimed to identify predictors of NA incidence and plaque vulnerability in patients with late ISR and the role of low-density lipoprotein cholesterol (LDL-C) levels in this process. A total of 216 patients with 216 lesions who underwent optical coherence tomography (OCT) before interventional procedure for late drug-eluting stent ISR were enrolled and divided into NA and non-NA groups based on OCT findings. Results showed that higher LDL-C levels were associated with NA, thin-cap fibroatheroma (TCFA), intimal disruption, plaque erosion, and thrombosis. Multivariate regression analysis revealed that the LDL-C level was an independent risk factor for NA and TCFA. The LDL-C levels exhibited a significant predictive value for NA and TCFA, surpassing other factors such as stent age and other lipid types. In conclusion, a high LDL-C level is an independent predictor of NA incidence and plaque vulnerability in patients with late ISR.

Impact of triglyceride-rich lipoproteins on early in-stent neoatherosclerosis formation in patients undergoing statin treatment

BACKGROUND

Neoatherosclerosis (NA), which refers to neointimal atherosclerosis within a stent, is considered one of the underlying causes of late-phase stent failure following a newer generation drug-eluting stent (DES) placement procedure. Even contemporary guideline-directed medical therapy may be insufficient to prevent NA.

OBJECTIVE

This study aimed to investigate how intricately lipid markers are associated with NA formation in the early phase of treatment with well-maintained low-density lipoprotein cholesterol (LDL-C) levels.

METHODS

We enrolled 114 consecutive patients undergoing statin treatment and percutaneous coronary intervention (PCI) with current-generation DES for coronary artery disease. At a median 12 months after PCI, optical coherence tomography (OCT) was performed. Various lipid markers, including LDL-C, triglyceride (TG), triglyceride-rich lipoprotein cholesterol (TRL-C), non-high-density lipoprotein cholesterol (non-HDL-C), malondialdehyde-modified LDL (MDA-LDL), and several apolipoproteins, were also evaluated.

RESULTS

NA was observed in 17 (14.9%) patients. The LDL-C level was equivalent in patients with or without NA (77.2 vs. 69.8 mg/dL; p=0.15). However, the levels of TG, apolipoprotein C3 (apoC3), TRL-C, non-HDL-C, and apolipoprotein B (apoB), and MDA-LDL were significantly higher in the patients with NA. Furthermore, multivariate logistic regression adjusting for HbA1c and stent duration revealed apoC3, TRL-C, non-HDL-C, apoB, and MDA-LDL levels as risk factors for NA. However, when apoB was included as a covariate, other factors became nonsignificant.

CONCLUSIONS

Abnormal triglyceride-rich lipoprotein metabolism and high atherogenic apoB-containing lipoprotein particle numbers are associated with the formation of NA in patients undergoing statin treatment at a median 12 months post-PCI.

Drug-Eluting Stent Restenosis: Modern Approach to a Classic Challenge

In-stent restenosis (ISR) is a recognized complication following percutaneous coronary intervention in which the luminal diameter is narrowed through neointimal hyperplasia and vessel remodeling. Although rates of ISR have decreased in most recent years owing to newer generation drug-eluting stents, thinner struts, and better intravascular imaging modalities, ISR remains a prevalent dilemma that proves to be challenging to manage. Several factors have been proposed to contribute to ISR formation, including mechanical stent characteristics, technical factors during the coronary intervention, and biological aspects of drug-eluting stents. Presentation of ISR can range from asymptomatic to late myocardial infarction and could be difficult to differentiate from acute thrombus formation. No definite guidelines are present on the management of ISR. In this review, we will discuss the mechanisms underlying ISR and provide insight into patient-related and procedural risk factors contributing to ISR, in addition to highlighting common treatment approaches utilized in the management of ISR.

Prevalence, Morphology, and Predictors of Intra-Stent Plaque Rupture in Patients with Acute Coronary Syndrome: An Optical Coherence Tomography Study

Previous studies have shown that plaque rupture (PR) is the most important cause of acute coronary syndrome (ACS). However, the potential impact of intra-stent PR on stent failure manifesting as ACS and the optical coherence tomography (OCT) features of these lesions was still less clear. Therefore, we aimed to investigate the characteristics of OCT-defined in-stent PR and identify the potential risk factors for PR in ACS patients. All 213 ACS patients were stratified into two groups according to the occurrence of in-stent PR. The baseline characteristics of all patients were investigated. A multivariable logistic regression was performed to identify factors associated with the formation of PR. OCT findings showed that 80 patients had in-stent PR, and 133 patients were without PR. Patients who suffered in-stent PR had higher blood lipid levels (P < .050) and longer duration of stent failure (P = .001). Moreover, thrombolysis in myocardial infarction (TIMI) 0/1 flow was more prone to the formation of PR (P = .010), and lesions in the PR group harbored more macrophages and cholesterol crystals (P < .001 and P = .024). On multivariate analysis, presentation of myocardial infarction (MI) and OCT findings of lipidic neointima length showed a 3.6-fold (P = .004) and 1.3-fold (P < .001) higher risk for occurrence of in-stent PR. ACS patients who suffered in-stent PR had a longer duration of stent failure and more ISR occurring in non-culprit vessels. Given the distinguishing features between ACS patients with in-stent PR and non-PR, potential targeted therapy was warranted to improve the prognosis of patients with in-stent PR.

Neoatherosclerosis prediction using plaque markers in intravascular optical coherence tomography images

Introduction

In-stent neoatherosclerosis has emerged as a crucial factor in post-stent complications including late in-stent restenosis and very late stent thrombosis. In this study, we investigated the ability of quantitative plaque characteristics from intravascular optical coherence tomography (IVOCT) images taken just prior to stent implantation to predict neoatherosclerosis after implantation.

Methods

This was a sub-study of the TRiple Assessment of Neointima Stent FOrmation to Reabsorbable polyMer with Optical Coherence Tomography (TRANSFORM-OCT) trial. Images were obtained before and 18 months after stent implantation. Final analysis included images of 180 lesions from 90 patients; each patient had images of two lesions in different coronary arteries. A total of 17 IVOCT plaque features, including lesion length, lumen (e.g., area and diameter); calcium (e.g., angle and thickness); and fibrous cap (FC) features (e.g., thickness, surface area, and burden), were automatically extracted from the baseline IVOCT images before stenting using dedicated software developed by our group (OCTOPUS). The predictive value of baseline IVOCT plaque features for neoatherosclerosis development after stent implantation was assessed using univariate/multivariate logistic regression and receiver operating characteristic (ROC) analyses.

Results

Follow-up IVOCT identified stents with (n = 19) and without (n = 161) neoatherosclerosis. Greater lesion length and maximum calcium angle and features related to FC were associated with a higher prevalence of neoatherosclerosis after stent implantation (p < 0.05). Hierarchical clustering identified six clusters with the best prediction p-values. In univariate logistic regression analysis, maximum calcium angle, minimum calcium thickness, maximum FC angle, maximum FC area, FC surface area, and FC burden were significant predictors of neoatherosclerosis. Lesion length and features related to the lumen were not significantly different between the two groups. In multivariate logistic regression analysis, only larger FC surface area was strongly associated with neoatherosclerosis (odds ratio 1.38, 95% confidence interval [CI] 1.05-1.80, p < 0.05). The area under the ROC curve was 0.901 (95% CI 0.859-0.946, p < 0.05) for FC surface area.

Conclusion

Post-stent neoatherosclerosis can be predicted by quantitative IVOCT imaging of plaque characteristics prior to stent implantation. Our findings highlight the additional clinical benefits of utilizing IVOCT imaging in the catheterization laboratory to inform treatment decision-making and improve outcomes.

Inflammatory Phenotype by OCT Coronary Imaging: Specific Features Among De Novo Lesions, In-Stent Neointima, and In-Stent Neo-Atherosclerosis

BACKGROUND

Coronary stenosis can be caused de novo atherosclerosis, in-stent restenosis, and in-stent neoatherosclerosis, three entities that develop from a diverse pathophysiological milieu.

OBJECTIVE

This study aims to investigate, using optical coherence tomography (OCT), whether or not coronary lesions related to these processes differ in their local inflammatory profile.

METHODS

Retrospective analysis of patients with diagnosed or suspected coronary lesions who had undergone OCT imaging for clinical reasons. Macrophage and intra-plaque neovascularization were assessed by OCT and used as surrogates of local inflammation. A significance level of < 0.05 was adopted as statistically significant.

RESULTS

From the 121 lesions, 74 were de novo, 29 were restenosis, and 18 were neoatherosclerosis. Neovascularization was found in 65.8% of de novo, 10.3% in restenosis, and 94.4% in neoatherosclerosis (p<0.01 for all). The volume of neovascularization was different among lesion types (950 vs. 0 vs. 6220, respectively [median values in 1000 x µm3/mm]; p<0.01 for all), which were significantly higher in neoatherosclerosis and lower in restenosis. The presence of macrophages differed among the lesions (95.9% in de novo vs. 6.9% in restenosis vs. 100% in neoatherosclerosis [p<0.01 for all]). Moreover, the intensity of macrophagic infiltration was different among lesion types (2.5 vs. 0.0 vs. 4.5, respectively [median values of macrophage score]; p<0.01 for all), significantly higher in neoatheroscleosis and lower in restenosis.

CONCLUSION

When compared using coronary OCT, de novo atherosclerosis, in-stent restenosis, and neoatherosclerosis presented markedly different inflammatory phenotypes.

Global research trends in in-stent neoatherosclerosis: A CiteSpace-based visual analysis

BACKGROUND

Recent studies have shown that in-stent neoatherosclerosis (ISNA/NA) is an important cause of late stent failure. A comprehensive understanding of the current state of research in this field will facilitate the analysis of its development trends and hot frontiers. However, no bibliometric correlation has been reported yet. Here, we analyze the relevant literature since the emergence of the concept and provide valuable insights.

METHODS

Publications were collected from the Web of Science Core Collection (WoSCC) and PubMed. Microsoft Excel, SPSS and CiteSpace were used to analyze and present the data.

RESULTS

A total of 498 articles were collected, with Japan and Cardiovasc Res Fdn being the main publishing forces in all country/region and institutions. J AM COLL CARDIOL is the journal with the most published and co-cited articles. According to co-citation analysis, optical coherence tomography, thrombosis, implantation, restenosis, drug-eluting stent, and bare metal stent have become more and more popular recently.

CONCLUSION

ISNA is a niche and emerging field. How to reduce the incidence of ISNA and improve the late patency rate of coronary stents may remain a hot spot for future research. The pathogenesis of ISNA also needs to be explored in more depth.

Prevalence and Impact of Neoatherosclerosis on Clinical Outcomes After Percutaneous Treatment of Second-Generation Drug-Eluting Stent Restenosis

BACKGROUND

Clinical and morphological factors associated with lipidic versus calcified neoatherosclerosis within second-generation drug-eluting stents and the impact of lipidic versus calcified neoatherosclerosis on long-term outcomes after repeat intervention have not been well studied.

METHODS

A total of 512 patients undergoing optical coherence tomography before percutaneous coronary intervention for second-generation drug-eluting stents in-stent restenosis were included. Neoatherosclerosis was defined as lipidic or calcified neointimal hyperplasia in ≥3 consecutive frames or ruptured lipidic neointimal hyperplasia. The primary outcome was target lesion failure (cardiac death, target vessel myocardial infarction, definite stent thrombosis, or clinically driven target lesion revascularization).

RESULTS

The overall prevalence of neoatherosclerosis was 28.5% (146/512): 56.8% lipidic, 30.8% calcified, and 12.3% both lipidic and calcific. The prevalence increased as a function of time from stent implantation: 20% at 1 to 3 years, 30% at 3 to 7 years, and 75% >7 years. Renal insufficiency, poor lipid profile, and time from stent implantation were associated with lipidic neoatherosclerosis, whereas severe renal insufficiency, female sex, and time from stent implantation were associated with calcified neoatherosclerosis. Multivariable Cox regression revealed that female sex and lipidic neoatherosclerosis were associated with more target lesion failure, whereas stent age and final minimum lumen diameter after reintervention were related to lower target lesion failure. Calcified neoatherosclerosis was not related to adverse events after reintervention for in-stent restenosis given a large enough minimum lumen diameter was achieved.

CONCLUSIONS

Lipidic but not calcified neoatherosclerosis was associated with poor subsequent outcomes after repeat revascularization if optimal stent expansion was achieved in lesions with calcified neoatherosclerosis.

Polymer–Metal Composite Healthcare Materials: From Nano to Device Scale

Metals have been investigated as biomaterials for a wide range of medical applications. At nanoscale, some metals, such as gold nanoparticles, exhibit plasmonics, which have motivated researchers’ focus on biosensor development. At the device level, some metals, such as titanium, exhibit good physical properties, which could allow them to act as biomedical implants for physical support. Despite these attractive features, the non-specific delivery of metallic nanoparticles and poor tissue–device compatibility have greatly limited their performance. This review aims to illustrate the interplay between polymers and metals, and to highlight the pivotal role of polymer–metal composite/nanocomposite healthcare materials in different biomedical applications. Here, we revisit the recent plasmonic engineered platforms for biomolecules detection in cell-free samples and highlight updated nanocomposite design for (1) intracellular RNA detection, (2) photothermal therapy, and (3) nanomedicine for neurodegenerative diseases, as selected significant live cell–interactive biomedical applications. At the device scale, the rational design of polymer–metallic medical devices is of importance for dental and cardiovascular implantation to overcome the poor physical load transfer between tissues and devices, as well as implant compatibility under a dynamic fluidic environment, respectively. Finally, we conclude the treatment of these innovative polymer–metal biomedical composite designs and provide a future perspective on the aforementioned research areas.

Hangover after Side Branch Stenting: The Discomfort Comes Afterwards

The authors report on a patient with recurrent angina at rest and on exertion 2 years after percutaneous revascularisation of the first diagonal branch (D1). Invasive coronary angiography with full functional testing was planned with the tentative diagnosis of coronary vascular dysfunction. Coronary angiography with functional testing revealed a haemodynamically significant intermediate stenosis at the D1–left anterior descending artery bifurcation. Optical coherence tomography demonstrated neointimal bridging and accelerated downstream atherosclerosis that was induced by protrusion of the previously implanted stent into the main branch. Although the overhanging stent was considered insignificant at first, it caused significant discomfort after 2 years. After provisional stenting of the main branch with crushing of the protruding stent and continuous medical treatment, the patient remained free of recurrent angina.

Morphological and Physiological Characteristics of Ruptured Plaques in Native Arteries and Neoatherosclerotic Segments: An OCT-Based and Computational Fluid Dynamics Study

Background

Intravascular imaging has been used to assess the morphology of lesions causing an acute coronary syndrome (ACS) in native vessels (NV) and identify differences between plaques that ruptured (PR) and caused an event and those that ruptured without clinical manifestations. However, there is no data about the morphological and physiological characteristics of neoatherosclerotic plaques that ruptured (PR-NA) which constitute a common cause of stent failure.

Methods

We retrospectively analyzed data from patients admitted with an acute myocardial infarction that had optical coherence tomography (OCT) imaging of the culprit vessel before balloon pre-dilation. OCT pullbacks showing PR were segmented at every 0.4 mm. The extent of the formed cavity, lipid and calcific tissue, thrombus, and macrophages were measured, and the fibrous cap thickness (FCT) and the incidence of micro-channels and cholesterol crystals were reported. These data were used to reconstruct a representative model of the native and neoatherosclerotic lesion geometry that was processed with computational fluid dynamics (CFD) techniques to estimate the distribution of the endothelial shear stress and plaque structural stress.

Result

Eighty patients were included in the present analysis: 56 had PR in NV (PR-NV group) and 24 in NA segments (PR-NA group). The PR-NV group had a larger minimum lumen area (2.93 ± 2.03 vs. 2.00 ± 1.26 mm², p = 0.015) but similar lesion length and area stenosis compared to PR-NA group. The mean FCT (186 ± 65 vs. 232 ± 80 μm, p = 0.009) and the lipid index was smaller (16.7 ± 13.8 vs. 25.9 ± 14.1, p = 0.008) while the of calcific index (8.3 ± 9.5 vs. 2.2 ± 1.6%, p = 0.002) and the incidence of micro-channels (41.4 vs. 12.5%, p = 0.013) was higher in the PR-NV group. Conversely, there was no difference in the incidence of cholesterol crystals, thrombus burden or the location of the rupture site between groups. CFD analysis revealed higher maximum endothelial shear stress (19.1 vs. 11.0 Pa) and lower maximum plaque structural stress (38.8 vs. 95.1 kPa) in the PR-NA compared to the PR-NV model.

Conclusion

We reported significant morphological and physiological differences between culprit ruptured plaques in native and stented segments. Further research is needed to better understand the causes of these differences and the mechanisms regulating neoatherosclerotic lesion destabilization.

Investigation Into the Risk Factors Related to In-stent Restenosis in Elderly Patients With Coronary Heart Disease and Type 2 Diabetes Within 2 Years After the First Drug-Eluting Stent Implantation

Background

The present study aims to explore risk factors related to in-stent restenosis (ISR) in elderly patients with coronary heart disease and type 2 diabetes within 2 years after the first drug-eluting stent (DES) implantation.

Methods

This case-control study retrospectively analyzed the clinical data of patients with coronary heart disease and diabetes undergoing percutaneous coronary intervention (PCI) in Shenzhen Sun Yat-sen Cardiovascular Hospital between January 2010 and March 2020. Univariate and multivariate models were used to assess independent factors for DES-ISR. Categorical principal component analysis of clinical variables was performed to determine important components for DES-ISR. Nomogram was constructed to quantitatively predict the probability of DES-ISR development. The diagnostic potential of clinical variables was determined by receiver operating characteristic curve.

Results

In the derivation cohort, 1,741 cases were included in this study, and a total of 227 pairs of cases and controls were generated by propensity score matching. In the validation cohort, 102 cases were included with 19 cases (18.6%) with DES-ISR. Glomerular filtration rate &lt;60 ml/min/1.73 m2, fasting blood glucose ≥6.5 mmol/L, multivessel coronary artery disease, coronary artery diffuse disease, PCI operation time (≥60 min), emergency PCI were associated with ISR. High Nomogram score was associated with the increased risk of ISR. Further analysis of the validation cohort showed that higher levels of HbA1c-coefficient of variation (CV) were significantly associated with the increased risk of ISR. HbA1c-CV exhibited good predictive ability for ISR in the validation cohort.

Conclusions

In conclusion, the fasting blood glucose level during the perioperative period of emergency PCI and the long-term variation of HbA1c during the follow-up period are related to the incidence of DES-ISR and the degree of stenosis. Reducing blood glucose fluctuations may decrease the risk of DES-ISR.

Comparison of neoatherosclerosis and a clinical outcomes between bioabsorbable versus durable polymer drug-eluting stent: Verification by optical coherence tomography analysis

BACKGROUND

Neoatherosclerosis after drug-eluting stent (DES) implantation is known to be related with increased risk of late restenosis and stent thrombosis. Neoatherosclerosis and relevant clinical outcomes between bioabsorbable polymer DES (BP-DES) and second-generation durable polymer DES (DP-DES) were evaluated by optical coherence tomography (OCT) analysis.

METHODS

A total of 311 patients (319 lesions) undergoing OCT analysis after DES implantation were enrolled and divided into two groups according to stent type (BP-DES [150 patients, 153 lesions] and DP-DES [161 patients, 166 lesions]). Follow-up OCT analysis was performed at least 9 months after index stent implantation. Neoatherosclerosis was defined as presence of thin-cap fibroatheroma, calcified plaque, and lipid plaque. Primary endpoint was the incidence of neoatherosclerosis, and the secondary endpoints were the occurrence of major adverse cardiac events (MACE), defined as a composite of death, myocardial infarction, target lesion revascularization, or stent thrombosis and to find independent predictors of neoatherosclerosis.

RESULTS

The incidence of neoatherosclerosis was lower in the BP-DES group than the DP-DES group (5.2% vs. 14.5%, p = 0.008), which was driven by lipid plaque. However, the incidence of MACE did not show statistical difference between the two groups in median 4-year follow-up (3.3% vs. 7.8%, hazard ratio 1.964, 95% confidence interval 0.688-5.611, p = 0.207). Less use of angiotensin converting enzyme inhibitors/angiotensin II receptor blockade and higher degree of neointimal hyperplasia remained independent predictors of neoatherosclerosis on Cox regression analysis.

CONCLUSIONS

Patients undergoing BP-DES implantation had lower incidence of neoatherosclerosis than DP-DES, which did not reach statistically better clinical outcomes.

In Stent Neo-Atherosclerosis: Pathophysiology, Clinical Implications, Prevention, and Therapeutic Approaches

Despite the dramatic improvements of revascularization therapies occurring in the past decades, a relevant percentage of patients treated with percutaneous coronary intervention (PCI) still develops stent failure due to neo-atherosclerosis (NA). This histopathological phenomenon following stent implantation represents the substrate for late in-stent restenosis (ISR) and late stent thrombosis (ST), with a significant impact on patient’s long-term clinical outcomes. This appears even more remarkable in the setting of drug-eluting stent implantation, where the substantial delay in vascular healing because of the released anti-proliferative agents might increase the occurrence of this complication. Since the underlying pathophysiological mechanisms of NA diverge from native atherosclerosis and early ISR, intra-coronary imaging techniques are crucial for its early detection, providing a proper in vivo assessment of both neo-intimal plaque composition and peri-strut structures. Furthermore, different strategies for NA prevention and treatment have been proposed, including tailored pharmacological therapies as well as specific invasive tools. Considering the increasing population undergoing PCI with drug-eluting stents (DES), this review aims to provide an updated overview of the most recent evidence regarding NA, discussing pathophysiology, contemporary intravascular imaging techniques, and well-established and experimental invasive and pharmacological treatment strategies.

Healed neointima of in-stent restenosis lesions in patients with stable angina pectoris: an intracoronary optical coherence tomography study

The phenomenon to heal neointimal rupture or thrombus after coronary stenting occurs as well as in native coronary artery. We investigated clinical characteristics and neointimal vulnerability of healed neointima by optical coherence tomography (OCT). We treated 67 lesions by percutaneous coronary intervention for in-stent restenosis (ISR) and conducted OCT examinations. Healed neointima was defined as neointima having one or more layers with different optical densities and a clear demarcation from underlying components. ISR with healed neointima was found in 49% (33/67) of the lesions. Compared to ISR without healed neointima, ISR with healed neointima showed significantly longer stent age (102 ± 72 vs. 31 ± 39 months, P < 0.001), lower frequency of dual antiplatelet therapy [42% (14/33) vs. 74% (25/34), P = 0.017], lower use of angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (ACE-I or ARB) [61% (20/33) vs. 91% (31/34), P = 0.028], lower usage of second-generation drug-eluting stents (DESs) [36% (12/33) vs. 63% (22/34), P = 0.029], higher usage of thick-strut stents [42% (14/33) vs. 15% (5/34), P = 0.012], larger neointimal area (6.8 ± 2.6 vs. 5.2 ± 1.8 mm², P = 0.005), higher incidence of thin-cap fibroatheroma [58% (19/33) vs. 21% (7/34), P = 0.002], neointimal rupture [45% (15/33) vs. 9% (3/34), P = 0.001], and lower incidence of stent underexpansion [15% (5/33) vs. 44% (15/34), P = 0.010]. In conclusions, ISR with healed neointima was associated with neointimal vulnerability, stent age, stent type, stent strut thickness, stent expansion, antiplatelet therapy, and use of ACE-I or ARB.

Overcoming challenges in refining the current generation of coronary stents

INTRODUCTION

Late stent thrombosis caused by delayed vascular healing and prolonged local inflammation were major drawbacks of 1^st generation drug-eluting stents (DES). Strut design, biocompatibility of polymer, and drug-release profiles were improved in 2^nd and 3rdgeneration DES. Accordingly, the indications for percutaneous coronary intervention with DES have been expanded to more complex patients and lesions. Despite these improvements, significant barriers such as greater flexibility in the duration of dual-antiplatelet therapy (DAPT) as well as reducing long-term stent-related events remain. To achieve ideal short- and long-term results, these existing limitations need to be overcome.

AREAS COVERED

We will discuss the current limitations of coronary DES and how they might be overcome from pathological and clinical viewpoints.

EXPERT OPINION

Optimizing DAPT duration after stent implantation and prevention of in-stent neoatherosclerosis are two major issues in current DES. Overcoming these drawbacks is a prerequisite toward achieving better short- and long-term clinical outcomes. New technologies including platform design, polymer types, and anti-proliferative agent itself might lead to further improvements. Although the initial experience with bioresorbable scaffold/stents (BRS) was disappointing, positive results of clinical studies regarding novel BRS are raising expectations. Overall, further device innovation is desired for overcoming the limitations of current DES.

Risk factors for revascularization and in-stent restenosis in patients with triple-vessel disease after second-generation drug-eluting stent implantation: a retrospective analysis

Objectives

Coronary artery disease (CAD) is a common cardiac disease with high morbidity and mortality, and triple-vessel disease (TVD) is a severe type of CAD. This study investigated risk factors for revascularization and in-stent restenosis (ISR) in TVD patients who underwent second-generation drug-eluting stent implantation.

Methods

A retrospective clinical study was conducted, and 246 triple-vessel disease (TVD) patients with 373 vessels after second-generation drug-eluting stent (DES) implantation who received follow-up coronary angiography (CAG) were consequently enrolled. According to the follow-up angiography, patients were categorized into the revascularization group and nonrevascularization group as well as the in-stent restenosis (ISR) group and non-ISR group. Univariate and multivariate logistic regression analyses were used to identify risk factors for revascularization and ISR. Receiver operating characteristic (ROC) curve with area under the curve (AUC) analysis was performed to assess the predictive power of these risk factors.

Results

In the median follow-up period of 28.0 (14.0, 56.0) months, 142 TVD patients (57.7%) with 168 vessels underwent revascularization, and ISR occurred in 43 TVD patients (17.5%) with 47 vessels after second-generation DES implantation. Compared to the nonrevascularization group, the revascularization group presented with an increased rate of current smoking and higher levels of TC, LDL-C, HDL-C, non-HDL-c, ApoB, neutrophils, and Hs-CRP as well as a longer follow-up of months but with a lower level of HDL-C. In addition, patients in the ISR group had an older age, longer follow-up (months) and elevated rates of current smoking and stage 4–5 chronic kidney disease (CKD4-5). In multivariate analysis, current smoking and higher non-HDL-c were independent risk factors for revascularization. In addition, older age, current smoking and CKD4-5 were considered independent risk factors for ISR. Importantly, the receiver operating characteristic curve showed that non-HDL-C and age displayed predictive power for revascularization and ISR, respectively.

Conclusion

Current smoking is an independent risk factor for both revascularization and in-stent restenosis. Higher non-HDL-c is independently related to revascularization; moreover, increased age and CKD4-5 are potential risk factors for ISR in TVD patients after second-generation drug-eluting stent implantation.

Serial Baseline, 12-, 24-, and 60-Month Optical Coherence Tomography Evaluation of ST Segment Elevation Myocardial Infarction Patients Treated with Absorb Bioresorbable Vascular Scaffold

Data on long-term neointimal healing and neoatherosclerosis progression after primary percutaneous coronary intervention (PCI) with implantation of everolimus-eluting bioresorbable vascular scaffold (BVS) (ABSORB BVS 1.0, Abbott Vascular) are limited. The mechanisms underlying very late scaffold failure remain to be further elucidated. This study sought to assess healing pattern and presence of neoatherosclerosis. This was a single-center, prospective, longitudinal study with serial optical coherence tomography (OCT) assessment at baseline, 12, 24 and 60 months after PCI performed in 12 patients presenting with ST-segment elevation myocardial infarction (STEMI). The median follow-up was 59 months. The diameter stenosis increased from 7.11 ± 4.99% at 1-year to 21.00 ± 11.31% at 5 years, (p = 0.03), whereas minimum lumen diameter remained stable throughout the follow-up period, as assessed by angiography. Minimum and mean lumen area declined over the 5-year follow-up by 1.00 ± 1.57 mm2 and 1.75 ± 0.87 mm2, respectively; a significant decrease in minimum and mean lumen area in the first two years, was followed by stable luminal dimensions between 2 and 5 years of follow-up. The lumen eccentricity (0.85 ± 0.03) and asymmetry (0.43 ± 0.10) indexes showed no change over 60-month follow-up. The incidence of atherosclerosis was high both in the in-scaffold (IS) and out-scaffold (OS) regions consisting of calcifications (IS = 100%, OS = 92%, p = 0.99), macrophages (IS = 92% and OS = 67%, p = 0.31), neovascularization (IS = 75%, OS = 50%, p = 0.40). In conclusion, serial OCT imaging up to 5 years after implantation of BVS in STEMI indicated complete scaffold resorption, stable lumen area following period of neointima growth in the first two years after PCI and high incidence of neoatherosclerosis.

Predictors and outcomes of neoatherosclerosis in patients with in-stent restenosis

BACKGROUND

In-stent restenosis (ISR), especially for neoatherosclerosis, is still a major problem of percutaneous coronary intervention (PCI) even in the drug-eluting stent (DES) era.

AIMS

The purpose of this study was to investigate the impact of neoatherosclerosis on prognosis after PCI for ISR.

METHODS

Between March 2009 and December 2017, 313 ISR lesions in patients undergoing an OCT-guided PCI in five hospitals were retrospectively enrolled. Neoatherosclerosis was defined as a lipid neointima or calcified neointima. We examined the association between neoatherosclerosis and the clinically driven target lesion revascularisation (CD-TLR) rates.

RESULTS

In 313 ISR lesions, 64 lesions (20.4%) had bare metal stents and 241 lesions (77.0%) had drug-eluting stents (DES). Among them, 47.0% of lesions (147 lesions) had neoatherosclerosis. A multivariate logistic regression analysis demonstrated that eGFR (odds ratio [OR] 0.986, 95% confidence interval [CI]: 0.974-0.998; p=0.023), the time from PCI to the ISR (OR 1.13, 95% CI: 1.06-1.22; p<0.001) and DES-ISR (OR 2.48, 95% CI: 1.18-5.43; p=0.019) were independent predictors for neoatherosclerosis. A multivariate regression analysis demonstrated that neoatherosclerosis was an independent predictor of CD-TLR.

CONCLUSIONS

In this multicentre ISR registry, OCT imaging demonstrated that eGFR, the time from PCI to the ISR and DES-ISR were independent predictors for neoatherosclerosis and that neoatherosclerosis in ISR lesions had a worse impact on the CD-TLR rate.

Risk factors of in-stent restenosis in patients with diabetes mellitus after percutaneous coronary intervention: A protocol for systematic review and meta-analysis

BACKGROUND

Percutaneous coronary intervention (PCI) has become one of the effective methods for the treatment of coronary heart disease (CHD). However, it is easy to have in-stent restenosis (ISR), even cardiovascular events after PCI, which affects the therapeutic effects. The incidence of ISR in diabetes mellitus (DM) patients increased by 2 to 4 times. Early identification of the risk factors of ISR in DM patients after PCI may help clinical staff to prevent and intervene as soon as possible, so it is very important to improve the clinical outcomes of DM patients. Although scholars at home and abroad have studied and summarized the risk factors of ISR in DM patients after PCI, the conclusions are different. Therefore, in this study, meta-analysis was used to summarize the risk factors of ISR in DM patients after PCI, and to explore the characteristics of high-risk groups of ISR, thus providing reference for early identification and prevention of ISR.

METHODS

We will search related literature from PubMed, Embase, Cochrane Library, Web of Science, China Biology Medicine Database, China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang Database. Eligible studies will be screened based on inclusion criteria. Meanwhile, data extraction, risk of bias assessment, publication bias assessment, subgroup analysis, and quality assessment will be performed. Review Manager Version 5.3 software will be applied for data analysis. Each process is independently conducted by 2 researchers. If there is any objection, it will be submitted to a third researcher for resolution.

RESULTS

We will disseminate the findings of this systematic review and meta-analysis via publications in peer-reviewed journals.

CONCLUSIONS

The results of this analysis can be used to generate a risk prediction model and provide an intervention strategy for the occurrence of ISR in DM patients after PCI.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/WC87Y.

Vascular Responses to First-Generation Sirolimus-Eluting Stents and Bare-Metal Stents Beyond 10 Years

Background: There are limited data regarding differences in vascular responses between first-generation sirolimus-eluting stents (1G-SES) and bare-metal stents (BMS) >10 years after implantation.

Methods and Results: We retrospectively investigated 223 stents (105 1G-SES, 118 BMS) from 131 patients examined by optical coherence tomography (OCT) >10 years after implantation. OCT analysis included determining the presence or absence of a lipid-laden neointima, calcified neointima, macrophage accumulation, malapposition, and strut coverage. Neoatherosclerosis was defined as having lipid-laden neointima. OCT findings were compared between the 1G-SES and BMS groups, and the predictors of neoatherosclerosis were determined. The median stent age at the time of OCT examinations was 12.3 years (interquartile range 11.0–13.2 years). There were no significant differences in patient characteristics between the 1G-SES and BMS groups. On OCT analysis, there was no difference in the prevalence of neoatherosclerosis and calcification between 1G-SES and BMS. Multivariable logistic regression analysis revealed that stent size, stent length, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use were significant predictors of neoatherosclerosis. In addition, uncovered and malapposed struts were more prevalent with 1G-SES than BMS.

Conclusions: After >10 years since implantation, the prevalence of neoatherosclerosis was no different between 1G-SES and BMS, whereas uncovered struts and malapposition were significantly more frequent with 1G-SESs.

Clinical significance of neoatherosclerosis observed at very late phase between 3 and 7 years after coronary stent implantation

BACKGROUND

Clinical significance of neoatherosclerosis (NA) observed at very late phase remains undetermined. We sought to investigate the association between NA observed by optical coherence tomography (OCT) 3-7 years after stenting and subsequent clinical outcomes.

METHODS

We investigated previously implanted stents without stent failure in the institutional OCT database at Tsuchiura Kyodo General Hospital. Qualitative and quantitative OCT analyses were performed. In patient-based analysis, major adverse cardiac events (MACE) included all-cause death, non-fatal myocardial infarction, and clinically driven revascularization. MACE-free survival rate was compared between patients with any stent showing NA (NA group) and those without NA (non-NA group). In stent-based analysis, the stent failure including target-lesion revascularization and stent thrombosis after the belated OCT examination were assessed.

RESULTS

A total of 187 patients with 308 stents undergoing belated OCT examination 3-7 years after implantation were investigated. Median duration from implantation to the belated OCT was 4.8 (3.8-5.8) years and NA was identified in 48 stents (15.6%) in 36 patients (19.3%). In patient-based analysis, during the median of 2.9 (2.1-3.6) years after belated OCT, MACE occurred in 9 patients (25.0%) with at least one stent showing NA (NA group) and 9 patients (6.0%) without NA (non-NA group) (p=0.002). Cox regression analysis revealed that NA was an independent predictor of MACE [hazard ratio (HR) 4.14 (1.58- 10.8), p=0.004]. In stent-based analysis, 7 stent failures were documented (stents with NA 10.0% vs. stents without NA 0.8%, p<0.01). NA was a significant predictor of stent failure [HR 9.17 (1.67- 50.3), p=0.011] at OCT examinations.

CONCLUSIONS

NA observed by OCT 3-7 years after implantation was associated with subsequent worse clinical outcomes in both patient-based and stent-based analysis.

Associations of myeloperoxidase, interleukin-17A and heparin-binding EGF-like growth factor levels with in-stent restenosis after percutaneous coronary intervention: a single-centre case-control study in China

OBJECTIVES

To investigate the changes in serum myeloperoxidase (MPO), interleukin (IL)-17A and heparin-binding EGF-like growth factor (HB-EGF) levels before and after percutaneous coronary intervention (PCI), and to evaluate the associations of MPO, IL-17A and HB-EGF levels with the 1-year restenosis rate.

DESIGN

Case-control study.

SETTINGS

Xiangyang Central Hospital between January 2012 and December 2017.

PARTICIPANTS

Patients with coronary heart disease who underwent PCI.

INTERVENTIONS

Not applicable.

PRIMARY AND SECONDARY OUTCOME MEASURES

Not applicable.

RESULTS

Finally, 407 and 132 patients were included in the control and in-stent restenosis (ISR) groups, respectively. The general clinical characteristics of the patients were not significantly different between the two groups. The MPO, IL-17A and HB-EGF levels were not significantly different between the two groups at baseline but significantly increased after PCI. The ISR group showed higher levels of MPO, IL-17A and HB-EGF compared with the control group at all postoperative time points. Multivariable analysis showed that MPO, IL-17A and HB-EGF were associated with increased ISR [MPO (OR=1.003; 95% CI: 1.001 to 1.005; p=0.002), IL-17A (OR=1.015; 95% CI: 1.009 to 1.020; p<0.0001) and HB-EGF (OR=2.256; 95% CI: 1.103 to 4.009; p=0.002)]. All three factors had sensitivity and specificity ≥68% for ISR.

CONCLUSIONS

HB-EGF could be used for the detection of ISR after PCI and could be of use for the prediction of ISR, but the value of MPO and IL-17A might be more limited. This will have to be validated in future studies.

Neointima characteristics as a prognostic marker for drug-coated balloon angioplasty in patients with in-stent restenosis: an optical coherence tomography study

BACKGROUND

Research has shown that the prognosis of in-stent restenosis (ISR) lesions after drug-coated balloon (DCB) angioplasty can differ in relation to in-stent neointimal characteristics. However, changes in neointima characteristics after DCB have not been studied. This study sought to investigate changes in neointima characteristics after DCB for ISR.

METHODS

From the Yonsei Optical Coherence Tomography (OCT) registry, data on DCBs performed in patients with ISR were collected. Neointima characteristics were categorized as homogeneous, heterogeneous, layered neointima, and neoatherosclerosis in each OCT procedure. Homogeneous and layered neointima were classified as a favorable neointima, while heterogeneous neointima and neoatherosclerosis were classified as an unfavorable neointima. The data of 67 ISR patients were analyzed.

RESULTS

The median duration between initial and follow-up OCT was 9.6 months. Patients with homogeneous and layered neointima on the initial OCT before DCB mostly appeared as homogeneous (66.7 and 68.2%, respectively) on the follow-up OCT, whereas most of the patients with heterogeneous neointima on the initial OCT remained unaltered (70%). Patients with unfavorable neointima at either the initial (P = 0.023) or the follow-up OCT (P = 0.037) had a worse major adverse cardiovascular event-free survival than the other patients. Patients who showed unfavorable neointima at both the initial and the follow-up OCT had the worst event-free survival (P = 0.038).

CONCLUSIONS

The follow-up OCT neointimal characteristics after DCB for ISR was associated with initial OCT characteristics. Sustained unfavorable neointima in serial OCT imaging may reflect poor prognosis in patients with ISR treated with DCB.

Plasma levels of miR-143 and miR-145 are associated with coronary in-stent restenosis within 1 year of follow-up after drug-eluting stent implantation

Background

ISR remains the major adverse outcome after percutaneous coronary intervention (PCI). MicroRNAs have been demonstrated to be associated with coronary plaque and stable in the blood and can be used as biomarkers/predictors. This study aimed to investigate whether circulating microRNAs could predict in-stent restenosis (ISR).

Methods

MicroRNA array was used to detect differently expressed microRNAs between 30 ISR patients and 30 non-ISR patients in the derivation cohort. Quantitative real-time polymerase chain reaction (qRT-PCR) was used to validate the microRNA array results and to detect levels of target microRNAs in the validation cohort. All patients were followed up for at least 1 year, and major adverse cardiac events (MACEs) were recorded. Univariate and multivariate logistic regression analysis were applied to find factors associated with ISR. Receiver operating characteristics (ROC) and Kaplan-Meier survival curves were used to analyze the predictive ability of the microRNA score for ISR.

Results

MicroRNA array and qRT-PCR showed that miR-143, 145, 425, 208, and let-7g were differently expressed between ISR patients and non-ISR patients. Multivariate analysis demonstrated that lower levels of mir-143 (OR =2.36, 95% CI: 1.43–3.67) and mir-145 (OR =2.12, 95% CI: 1.56–3.48) were associated with ISR. MicroRNA scores differed statistically between ISR patients and non-ISR patients (49.18±2.05 vs. 52.10±2.41, P<0.01) and has predictive ability for ISR with an area under the curve (AUC) of 0.8206 (95% CI: 0.7155–0.9256, P<0.01). In the validation cohort, Kaplan-Meier survival curves demonstrated that patients with higher microRNA scores have better prognosis in 1 year of follow-up.

Conclusions

A lower plasma level of mir-143/145 predicts a higher risk of ISR and a worse outcome.

Influence of neoatherosclerosis on prognosis and treatment response in patients with in-stent restenosis

INTRODUCTION AND OBJECTIVES

Neoatherosclerosis is one of the causes of in-stent restenosis (ISR). Our objective was to evaluate the influence of neoatherosclerosis on prognosis and treatment response in patients with ISR.

METHODS

This is a pooled analysis of the optical coherence tomography (OCT)-substudies of 2 multicenter, randomized clinical trials, RIBS IV and V, comparing treatment with paclitaxel-coated balloon vs everolimus-eluting stent in patients with ISR. OCT evaluation was performed at baseline and at 6 to 9 months. Neoatherosclerosis was defined in baseline OCT as neointima with calcified or lipid content. We evaluated the angiographic and OCT results at 6 to 9 months and the occurrence of major adverse cardiovascular events at 3 years of follow-up in patients with and without neoatherosclerosis treated with paclitaxel-coated balloon or everolimus-eluting stents.

RESULTS

Sixty-four patients underwent OCT at the time of the index procedure. Neoatherosclerosis was documented in 23 (36%) lesions. Angiographic follow-up at 6 to 9 months showed no differences in restenosis [5 (24%) vs 6 (15%) P=.49], minimum lumen diameter (1.79±0.7 vs 1.94±0.6mm; P=.41) or late loss (0.33±0.7 vs 0.15±0.5; P=.34) in patients with and without neoatherosclerosis, respectively. Follow-up OCT confirmed the absence of differences in quantitative parameters and the characteristics of tissue coverage between the 2 groups. At 3 years of follow-up, the major adverse cardiovascular events rate was 3 (13%) vs 5 (12%) in the neoatherosclerosis and nonneoatherosclerosis groups (HR, 0.94; 95%CI, 0.22-3.93; P=.93).

CONCLUSIONS

In this limited study population, OCT-defined neoatherosclerosis did not seem to influence acute and long-term outcomes in patients randomized to paclitaxel-coated balloon or everolimus-eluting stents for ISR.

Impact of different coronary angioscopic findings on arterial healing one year after bioresorbable-polymer and second-generation durable-polymer drug-eluting stent implantation

BACKGROUND

The advantage of using bioresorbable-polymer drug-eluting stent (BP-DES) compared with second-generation durable-polymer drug-eluting stent (2G DP-DES) still remains controversial in clinical situations. The purpose of this study to evaluate the degree of re-endothelialization and the prevalence of high-grade yellow-colored plaque (YCP), which might concern arterial healing after BP-DES and 2G DP-DES implantation using a high-resolution coronary angioscopy (CAS).

METHODS

In total, 104 DESs (52: 2G DP-DES and 52: BP-DES) were prospectively observed using CAS 12±1 months after coronary intervention. The grade of neointimal coverage (NIC) over the stent was scored on a 4-point scale from 0 (no coverage) to 3 (complete coverage). YCP grade was also scored on a 4-point scale as 0 (white) to 3 (intensive yellow). High-grade YCP was defined as maximum grade ≥2. Moreover, the prevalence of high-grade YCP and the incidence of thrombus were investigated.

RESULTS

BP-DES revealed better dominant NIC grade and less NIC heterogeneity than 2G DP-DES (p=0.0001 and p=0.015, respectively). The prevalence of high-grade YCP was lower for BP-DES than for 2G DP-DES (p=0.05). However, the incidence of thrombus was not significantly different (p=0.41). Multivariate analysis identified that low-density lipoprotein cholesterol levels [odds ratio (OR), 1.03; 95% Confidence Interval (CI): 1.01-1.06, p=0.01] and the usage of BP-DES [OR, 0.36; 95% CI: 0.14-0.91, p=0.03] as independent predictors of high-grade YCP.

CONCLUSIONS

Compared with 2G DP-DES, BP-DES was less heterogeneous and well-covered NIC and less prevalence of the high-grade YCP implying optimal arterial healing.

In-stent restenosis of drug-eluting stents in patients with diabetes mellitus: Clinical presentation, angiographic features, and outcomes

Objective:

Diabetes mellitus (DM) is a risk factor for developing in-stent restenosis (ISR) following percutaneous coronary intervention (PCI). This study aimed to examine the presentation and outcomes of drug-eluting stent (DES) ISR in diabetics.

Methods:

This retrospective study included consecutive patients with clinical DES-ISR, who were hospitalized between January 2013 and December 2017 and who were grouped based on the presence or absence of DM. Clinical, angiographic features and 1-year outcomes [composite of death, myocardial infarction (MI), and repeat-target lesion revascularization] were compared.

Results:

Baseline characteristics of the DM group (n=109) were comparable to the non-DM group (n=82), except for the higher prevalence of hypertension and dyslipidemia in the former (60.6% vs. 46.3%, p=0.050; 74.4% vs. 57.8%, p=0.034, respectively). Clinical presentation was similar in both groups [acute coronary syndrome (ACS): 62.4% vs. 61%, p=0.843; MI: 34.9% vs. 34.1%, p=0.918). Diabetics had a higher prevalence of stent-edge restenosis (20.3% vs. 9.2%, p=0.019). The treatment strategy was similar in both groups with 52.3% in the DM group and 57.3% in the non-DM group undergoing PCI (p=0.513). One-year outcomes of the DM group were not different from those of the non-DM group (14.7% vs. 17.1%, p=0.683). Age [hazard ratio (HR), 1.05; 95% confidence interval (CI), 1.01–1.10; p=0.017], MI presentation (HR, 2.34; 95% CI, 1.14–4.80; p=0.020), and chronic kidney disease (CKD: HR, 2.82; 95% CI, 1.21–6.58; p=0.016) were predictors of poor outcomes.

Conclusion:

Stent-edge restenosis is more common in diabetics. Clinical presentation and 1-year outcomes following DES-ISR are similar in diabetics and non-diabetics. Age, MI presentation, CKD, and not DM were predictors of poor outcomes following DES-ISR.

In-stent restenosis of drug-eluting stents: clinical presentation and outcomes in a real-world scenario

BACKGROUND

Drug-eluting stents (DES) have substantially reduced the incidence of coronary in-stent restenosis (ISR), but the problem persists. Clinical presentation and outcomes of DES-ISR in a real-world scenario remains underreported.

RESULTS

In this retrospective study, we examined medical records of 191 consecutive patients with DES-ISR (210 ISR lesions) hospitalized between January 2013 and December 2017. ISR clinical presentation was classified as acute coronary syndrome (ACS) or non-ACS. Clinical, angiographic features and 1-year outcomes [composite of death, myocardial infarction (MI) and repeat-target lesion revascularization] for these two groups were compared. The mean age of study population was 61 ± 10 years and 81.2% were males. ACS was the dominant clinical presentation mode occurring in 118 (61.8%) patients. MI was seen in 66 (34.6%) patients. Female gender (odds ratio, 2.71; 95% confidence interval [CI], 1.13-6.52; P = 0.026) and chronic kidney disease (odds ratio, 3.85; 95% CI, 1.05-14.20; P = 0.043) correlated significantly with ACS ISR presentation. A majority [104 (54.5%)] of patients underwent percutaneous coronary intervention (PCI), of whom 72 (69.2%) received a new DES. The rest either underwent CABG (26.2%) or received medical therapy (19.4%). Patients presenting with ACS had a significantly worse clinical outcome at 1-year follow-up (ACS versus non-ACS presentation: hazard ratio [HR], 2.66; 95% CI, 1.09-6.50; P = 0.032).

CONCLUSIONS

DES-ISR presents most commonly as ACS. Female gender and chronic kidney disease seem to be associated with ACS presentation. ACS presentation of ISR is associated with worse 1-year outcomes. Early identification of those with ACS risk and closer follow-up may improve outcomes.

Neoatherosclerosis 5 Years After Bioresorbable Vascular Scaffold Implantation

BACKGROUND

Data regarding neoatherosclerosis after everolimus-eluting bioresorbable vascular scaffold (BVS) (ABSORB BVS Rev. 1.1, Abbott Vascular, Santa Clara, California) implantation are limited.

OBJECTIVES

This study investigated the findings of neoatherosclerosis at 5 years after BVS 1.1 implantation by using multi-imaging modalities, including optical coherence tomography (OCT).

METHODS

Patients included in the ABSORB EXTEND (ABSORB EXTEND Clinical Investigation) trial at Shonan Kamakura General Hospital underwent OCT at baseline after the index procedure and at 1 and 5 years. Intimal plaque distributions in the in-scaffold and out-scaffold segments were analyzed.

RESULTS

Twenty patients (22 lesions) with stable angina pectoris were enrolled. The median follow-up duration was 67 months (interquartile range: 65 to 69 months), and the mean age was 69 ± 8 years. Patients with diabetes mellitus (25%) were included. Based on the baseline angiogram, 10 (46%) lesions were type B2/C lesions. At 1 and 5 years of follow-up, significant differences in the prevalence of in-scaffold lipid-laden neointima (17% vs. 61%; p = 0.04), calcification (28% vs. 94%; p < 0.01), neovascularization (6% vs. 78%; p < 0.01), and thin-cap fibroatheroma (0% vs. 22%; p = 0.02) were found. In the out-scaffold segments, no significant difference in the plaque prevalence between 1 and 5 years was noted.

CONCLUSIONS

The occurrence and progression of in-scaffold neoatherosclerosis with luminal narrowing was observed at 5 years after BVS 1.1 implantation. The small size of the current study warrants confirmation in larger study. (ABSORB EXTEND Clinical Investigation [ABSORB EXTEND]; NCT01023789).

The negative affectivity dimension of Type D personality is associated with in-stent neoatherosclerosis in coronary patients with percutaneous coronary intervention: An optical coherence tomography study

OBJECTIVE

In-stent neoatherosclerosis (ISNA) is involved in the pathogenesis of in-stent restenosis and major adverse cardiac events (MACE) in patients with coronary artery disease (CAD) after percutaneous coronary intervention (PCI). We aimed to explore the association between Type D personality and ISNA via in vivo optical coherence tomography (OCT).

METHODS

One hundred and fifty-six patients with CAD completed the Type D Scale-14 and underwent in vivo measurement of in-stent neoatherosclerosis by OCT. The Type D construct was analyzed as both the dichotomous and the dimension constructs.

RESULTS

After adjusting for demographic and clinical factors and presenting as a dichotomous construct, Type D personality was independently associated with the presence of in-stent neoatherosclerosis (odds ratio [OR] = 2.99, 95% confidence interval [CI] = 1.35-6.63, p = 0.007) and in-stent thin-cap fibroatheroma (OR = 2.81, 95% CI = 1.27-6.23, p = 0.01). Meanwhile, the multiple logistic regression also showed that the main effect of negative affectivity was an independent risk factor of in-stent neoatherosclerosis (OR = 1.85, 95% CI = 1.25-2.75, p = 0.002) and in-stent thin-cap fibroatheroma (OR = 1.77, 95% CI = 1.18-2.67, p = 0.006). However, the main effects of social inhibition with in-stent neoatherosclerosis and in-stent thin-cap fibroatheroma (OR = 0.98, 95% CI = 0.64-1.52, p = 0.94; OR = 0.94, 95% CI = 0.63-1.39, p = 0.75, respectively) as well as the interaction of negative affectivity and social inhibition were not significant (OR = 0.71, 95% CI = 0.69-1.81, p = 0.11; OR = 0.72, 95% CI = 0.47-1.08, p = 0.12, respectively).

CONCLUSIONS

Type D personality was found to be independently associated with in-stent neoatherosclerosis via OCT in patients with CAD after PCI. It was negative affectivity, not social inhibition, that affected the occurrence of the in-stent neoatherosclerosis, these results challenged the usefulness of the Type D construct. Our findings may provide new insights regarding the mechanisms of the association between Type D personality and MACE after PCI.

Impact of neointimal tissue characterization and heterogeneity of bare-metal stents and drug-eluting stents on the time course after stent implantation evaluated by integrated backscatter intravascular ultrasound

Pathological studies have suggested the different process of in-stent restenosis (ISR) of bare-metal stents (BMS) and drug-eluting stents (DES). Here, we evaluated the components of neointimal tissue using integrated backscatter intravascular ultrasound (IB-IVUS) and focused on the time course after stent implantation and tissue signal distribution. We evaluated 125 lesions of 125 patients who underwent target lesion revascularization for ISR (BMS: n = 73, DES: n = 52). Volume analysis of a 4-mm length centered on a minimum lumen area in every 1-mm cross-sectional area was performed. For IB-IVUS analysis, color-coded maps were constructed from the default setting based on the integrated backscatter (IB) values (middle-IB value, green: fibrous and low-IB value, blue: lipid pool). For the neointimal tissue volume, we evaluated the ratios of the green (%G) and blue (%B) areas. Tissue signal distribution (TD) was also obtained from the default setting based on IB values in each pixel of IB-IVUS imaging. We compared values of neointimal tissues measured by IB-IVUS between the DES and BMS and time course. The observed period was longer after BMS implantation than after DES implantation (BMS: 2545 days, DES: 1233 days, p < 0.001). Overall, %G and %B were similar between the BMS and DES groups (%G: 55% and 51%, respectively, p = 0.10; %B: 36% and 38%, respectively, p = 0.51); however, TD was significantly higher in the DES group than in the BMS group (1091 vs. 1367, p < 0.001). TD in the DES group remained high during the follow-up periods. However, TD in the BMS group was low in the early phase and significantly increased over time (r = 0.56, p < 0.001). When analyzing the ISR within 2 years after stent implantation, the BMS was distinguished with a sensitivity of 66% and a specificity of 90% (cut-off value: TD = 1135, area under the curve 0.83, 95% confidence interval 0.74-0.92). TD could differentiate neointimal tissue after BMS implantation in the early phase. TD can be a useful index in the observation of neoatherosclerosis.

Contemporary Management of Stent Failure: Part One

The occurrence of in-stent restenosis (ISR) still remains a daunting challenge in the current era, despite advancements in coronary intervention technology. The authors explore the underlying pathophysiology and mechanisms behind ISR, and describe how the use of different diagnostic tools helps to best elucidate these. They propose a simplistic algorithm to manage ISR, including a focus on how treatment strategies should be selected and a description of the contemporary technologies available. This article aims to provide a comprehensive outline of ISR that can be translated into evidence-based routine clinical practice, with the aim of providing the best outcomes for patients.

Impact of low tissue backscattering by optical coherence tomography on endothelial function after drug-eluting stent implantation

This study evaluated the impact of optical coherence tomography (OCT)-derived low-backscattered tissue on mid-term coronary endothelial function after drug-eluting stent (DES) implantation. Although OCT enables detailed in vivo evaluation of neointimal tissue characterization after DES implantation, its association with physiological vascular healing response is unclear. Thirty-three stable angina pectoris patients underwent OCT examination and endothelial function testing with intracoronary infusion of incremental doses of acetylcholine 8-month after DES implantation in a single lesion of the left anterior descending artery. Neointimal tissue was classified into two patterns based on the predominant OCT light backscatter: high backscatter and low backscatter. Although the presence of uncovered or malapposed stent strut was not associated with the degree of vasoconstriction, the degree of vasoconstriction was significantly greater in the DES with low-backscattered neointima than in the DES without low-backscattered neointima (- 32.1 ± 25.7 vs. - 4.1 ± 20.1%, p = 0.003). Moreover, there was an inverse linear relationship between low backscatter tissue index and degree of vasoconstriction after acetylcholine infusion (r = 0.50 and p = 0.003). The endothelium-dependent vasomotor response after 8-month of DES was impaired in patients with low neointimal tissue backscatter on OCT imaging. OCT assessment of low-backscattered tissue may be used as surrogate markers for impairment of endothelial function after DES.

Implications of the local hemodynamic forces on the formation and destabilization of neoatherosclerotic lesions

OBJECTIVE

To examine the implications of endothelial shear stress (ESS) distribution in the formation of neoatherosclerotic lesions.

METHODS

Thirty six patients with neoatherosclerotic lesions on optical coherence tomography (OCT) were included in this study. The OCT data were used to reconstruct coronary anatomy. Blood flow simulation was performed in the models reconstructed from the stent borders which it was assumed that represented the lumen surface at baseline, immediate after stent implantation, and the estimated ESS was associated with the neointima burden, neoatherosclerotic burden and neointima characteristics. In segments with neointima rupture blood flow simulation was also performed in the model representing the lumen surface before rupture and the ESS was estimated at the ruptured site.

RESULTS

An inverse association was noted between baseline ESS and the incidence and the burden of neoatherosclerotic (β = -0.60, P < 0.001, and β = -4.05, P < 0.001, respectively) and lipid-rich neoatherosclerotic tissue (β = -0.54, P < 0.001, and β = -3.60, P < 0.001, respectively). Segments exposed to low ESS (<1 Pa) were more likely to exhibit macrophages accumulation (28.2% vs 10.9%, P < 0.001), thrombus (11.0% vs 2.6%, P < 0.001) and evidence of neointima discontinuities (8.1% vs 0.9%, P < 0.001) compared to those exposed to normal or high ESS. In segments with neointima rupture the ESS was high at the rupture site compared to the average ESS over the culprit lesion (4.00 ± 3.65 Pa vs 3.14 ± 2.90 Pa, P < 0.001).

CONCLUSIONS

Local EES is associated with neoatherosclerotic lesion characteristics, which suggests involvement of ESS in the formation of vulnerable plaques in stented segments.