title: Optical coherence tomographic analysis of in-stent neoatherosclerosis after drug-eluting stent implantation.
abstract: BACKGROUND
  We report findings from optical coherence tomography (OCT) of in-stent neoatherosclerosis as a cause of drug-eluting stent (DES) failure.
  
  
  RESULTS
  Optical coherence tomography and grayscale and virtual histology intravascular ultrasound were performed in 50 patients (30 stable, 20 unstable angina) with 50 DES in-stent restenosis lesions and intimal hyperplasia >50% of stent area. Median follow-up time was 32.2 months. Overall, 26 lesions (52%) had at least 1 OCT-defined in-stent thin-cap fibroatheroma (TCFA)-containing neointima and 29 (58%) had at least 1 in-stent neointimal rupture. Patients presenting with unstable angina showed a thinner fibrous cap (55 μm [interquartile range 42 to 105 μm] versus 100 μm [interquartile range 60 to 205 μm], P=0.006) and higher incidence of OCT-defined TCFA-containing neointima (75% versus 37%, P=0.008), intimal rupture (75% versus 47%, P=0.044), thrombi (80% versus 43%, P=0.010), and red thrombi (30% versus 3%, P=0.012) than stable patients. Fibrous cap thickness negatively correlated with follow-up time (r=-0.318, P=0.024). Compared with DES <20 months after implantation (the best cut-off to predict TCFA-containing neointima), DES ≥20 months after implantation had a higher incidence of TCFA-containing neointima (69% versus 33%, P=0.012) and red thrombi (27% versus 0%, P=0.007). Patients with unstable (versus stable) angina had an increasing number of unstable OCT findings including TCFA-containing neointima, neointima rupture, and thrombus (P=0.027). The rate of agreement between grayscale intravascular ultrasound and OCT for detecting intimal rupture was 50% and for detecting thrombus was 44%. The agreement between virtual histology intravascular ultrasound and OCT for identifying TCFA-containing neointima was 78%.
  
  
  CONCLUSIONS
  In-stent neoatherosclerosis may be an important mechanism of DES failure, especially late after implantation.
authors.affiliation: Professor of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, South Korea.
authors.forename: Soo-Jin
authors.initials: SJ
authors.lastname: Kang
authors.forename: Gary S
authors.initials: GS
authors.lastname: Mintz
authors.forename: Takashi
authors.initials: T
authors.lastname: Akasaka
authors.forename: Duk-Woo
authors.initials: DW
authors.lastname: Park
authors.forename: Jong-Young
authors.initials: JY
authors.lastname: Lee
authors.forename: Won-Jang
authors.initials: WJ
authors.lastname: Kim
authors.forename: Seung-Whan
authors.initials: SW
authors.lastname: Lee
authors.forename: Young-Hak
authors.initials: YH
authors.lastname: Kim
authors.forename: Cheol
authors.initials: C
authors.lastname: Whan Lee
authors.forename: Seong-Wook
authors.initials: SW
authors.lastname: Park
authors.forename: Seung-Jung
authors.initials: SJ
authors.lastname: Park
mesh_terms: D000368:Aged; D050197:Atherosclerosis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D023903:Coronary Restenosis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D054855:Drug-Eluting Stents / Q000009:adverse effects*; D004868:Equipment Failure; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058226:Plaque, Atherosclerotic / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D041623:Tomography, Optical Coherence / Q000379:methods*; D017211:Treatment Failure; D017539:Tunica Intima / Q000000981:diagnostic imaging; D017540:Tunica Media / Q000000981:diagnostic imaging; D018084:Ultrasonography, Interventional