title: An intravascular ultrasound analysis of the mechanisms of restenosis comparing drug-eluting stents with brachytherapy.
abstract: There are treatment failures after de novo drug-eluting stent (DES) implantation and after treatment with DESs or vascular brachytherapy (VBT) of in-stent restenosis (ISR) lesions. We studied 38 patients who presented with DES failure (26 patients after de novo DES implantation and 12 patients after DES treatment of ISR) and 30 patients who presented with VBT failure (all after treatment of ISR). Standard clinical data were collected and volumetric intravascular ultrasound was measured. Patients who presented with DES failures were 58.8 +/- 9.6 years of age and those who presented with VBT failures were 59.8 +/- 8.7 years of age; 60.5% of DES and 58.6% of VBT failures were in men; 31.5% of DES failures and 46.6% of VBT failures occurred in diabetic patients; and times to presentation were 210 +/- 101 days in DES failures and 510 +/- 527 days in VBT failures (p = 0.001). Minimal stent area was significantly larger in VBT than in the 2 DES failure groups (de novo DES implantation and DES treatment of ISR, p <0.0001); this was associated with more neointimal hyperplasia in VBT failures (p <0.0001). After it was normalized to stent length, intimal hyperplasia was diffusely distributed in VBT failures; conversely, DES failures were associated with less intimal hyperplasia and the intimal hyperplasia was mostly focal, with greater accumulation in the proximal and mid segments. In conclusion, VBT failures were caused by significant, recurrent, and diffuse intimal hyperplasia in the setting of adequate stent expansion, whereas DES failures were caused by only modest, but focal, intimal hyperplasia in the setting of DES underexpansion.
authors.affiliation: Cardiovascular Research Institute/Medstar Research Institute, Washington Hospital Center, Washington, DC, USA.
authors.forename: Sang-Wook
authors.initials: SW
authors.lastname: Kim
authors.forename: Gary S
authors.initials: GS
authors.lastname: Mintz
authors.forename: Esteban
authors.initials: E
authors.lastname: Escolar
authors.forename: Patrick
authors.initials: P
authors.lastname: Ohlmann
authors.forename: Jerzy
authors.initials: J
authors.lastname: Pregowski
authors.forename: Pawel
authors.initials: P
authors.lastname: Tyczynski
authors.forename: Salah-Eddine
authors.initials: SE
authors.lastname: Hassani
authors.forename: Augusto D
authors.initials: AD
authors.lastname: Pichard
authors.forename: Lowell F
authors.initials: LF
authors.lastname: Satler
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Kent
authors.forename: William O
authors.initials: WO
authors.lastname: Suddath
authors.forename: Ron
authors.initials: R
authors.lastname: Waksman
authors.forename: Neil J
authors.initials: NJ
authors.lastname: Weissman
mesh_terms: D001918:Brachytherapy; D017023:Coronary Angiography; D023903:Coronary Restenosis / Q000000981:diagnostic imaging* / Q000517:prevention & control; D016503:Drug Delivery Systems; D005260:Female; D006801:Humans; D006965:Hyperplasia / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D015607:Stents; D017211:Treatment Failure; D017539:Tunica Intima / Q000473:pathology*; D018084:Ultrasonography, Interventional