Re-examining minimal luminal diameter relocation and quantitative coronary angiography--intravascular ultrasound correlations in stented saphenous vein grafts: methodological insights from the randomised RRISC trial.
OBJECTIVE
Angiographic parameters (such as late luminal loss) are common endpoints in drug-eluting stent trials, but their correlation with the neointimal process and their reliability in predicting restenosis are debated.


RESULTS
Using quantitative coronary angiography (QCA) data (49 bare metal stent and 44 sirolimus-eluting stent lesions) and intravascular ultrasound (IVUS) data (39 bare metal stent and 34 sirolimus-eluting stent lesions) from the randomised Reduction of Restenosis In Saphenous vein grafts with Cypher stent (RRISC) trial, we analysed the "relocation phenomenon" of QCA-based in-stent minimal luminal diameter (MLD) between post-procedure and follow-up and we correlated QCA-based and IVUS-based restenotic parameters in stented saphenous vein grafts. We expected the presence of MLD relocation for low late loss values, as MLD can "migrate" along the stent if minimal re-narrowing occurs, while we anticipated follow-up MLD to be located close to post-procedural MLD position for higher late loss. QCA-based MLD relocation occurred frequently: the site of MLD shifted from post-procedure to follow-up an "absolute" distance of 5.8 mm [2.5-10.2] and a "relative" value of 29% [10-46]. MLD relocation failed to correlate with in-stent late loss (rho = 0.14 for "absolute" MLD relocation [p = 0.17], and rho=0.03 for "relative" relocation [p = 0.811). Follow-up QCA-based and IVUS-based MLD values well correlated in the overall population (rho = 0.76, p < 0.001), but QCA underestimated MLD on average 0.55 +/- 0.49 mm, and this was mainly evident for lower MLD values. Conversely, the location of QCA-based MLD failed to correlate with the location of IVUS-based MLD (rho = 0.01 for "absolute" values--in mm [p = 0.911, rho = 0.19 for "relative" values--in % [p = 0.111). Overall, the ability of late loss to "predict" IVUS parameters of restenosis (maximum neointimal hyperplasia diameter, neointimal hyperplasia index and maximum neointimal hyperplasia area) was moderate (rho between 0.46 and 0.54 for the 3 IVUS parameters).


CONCLUSIONS
These findings suggest the need for a critical re-evaluation of angiographic parameters (such as late loss) as endpoints for drug-eluting stent trials and the use of more precise techniques to describe accurately and properly the restenotic process.
Semeraro
Oscar
O
Antwerp Cardiovascular Institute Middelheim, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium.
Agostoni
Pierfrancesco
P
Verheye
Stefan
S
Van Langenhove
Glenn
G
Van den Heuvel
Paul
P
Convens
Carl
C
Van den Branden
Frank
F
Bruining
Nico
N
Vermeersch
Paul
P
D015906:Angioplasty, Balloon, Coronary / Q000295:instrumentation*; D002317:Cardiovascular Agents / Q000008:administration & dosage; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D023903:Coronary Restenosis / Q000209:etiology / Q000473:pathology / Q000628:therapy*; D004311:Double-Blind Method; D054855:Drug-Eluting Stents; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000473:pathology / Q000628:therapy*; D006801:Humans; D008670:Metals; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D015203:Reproducibility of Results; D012501:Saphenous Vein / Q000000981:diagnostic imaging / Q000473:pathology*; D020123:Sirolimus / Q000008:administration & dosage; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional; D014654:Vascular Patency
D002317:Cardiovascular Agents; D008670:Metals; D020123:Sirolimus