Increased thin-cap neoatheroma and periprocedural myocardial infarction in drug-eluting stent restenosis: multimodality intravascular imaging of drug-eluting and bare-metal stents.
BACKGROUND
Re-endothelialization is delayed after drug-eluting stent (DES) implantation. In this setting, neointima is more prone to become lipid laden and develop neoatherosclerosis (NA), potentially increasing plaque vulnerability.


RESULTS
Optical coherence tomography and near-infrared spectroscopy with intravascular ultrasound were used to characterize NA in 65 (51 DES and 14 bare-metal stents) consecutive symptomatic patients with in-stent restenosis. Median duration poststent implantation was 33 months. Optical coherence tomography-verified NA was observed in 40 stents with in-stent restenosis (62%), was more prevalent in DES than bare-metal stents (68% versus 36%; P=0.02), and demonstrated significantly higher prevalence of thin-cap neoatheroma (47% versus 7%; P=0.01) in DES. Near-infrared spectroscopy assessment demonstrated that the total lipid core burden index (34 [interquartile range, 12-92] versus 9 [interquartile range, 0-32]; P<0.001) and the density of lipid core burden index (lipid core burden index/4 mm, 144 [interquartile range, 60-285] versus 26 [interquartile range, 0-86]; P<0.001) were higher in DES compared with bare-metal stents. Topographically, NA was classified as I (thin-cap NA), II (thick-cap NA), and III (peri-strut NA). Type I thin-cap neoatheroma was more common in DES (20% versus 3%; P=0.01) and in areas of the stented segment without significant in-stent restenosis (71%). Periprocedural myocardial infarction occurred only in DES (11 versus 0; P=0.05), of which 6 (55%) could be attributed to segments with >70% in-stent restenosis. By logistic regression, prior DES was the only independent predictor of both NA (odds ratio, 7.0; 95% confidence interval, 1.7-27; P=0.006) and periprocedural myocardial infarction (odds ratio, 1.8; 95% confidence interval, 1.1-2.4; P=0.05).


CONCLUSIONS
In-stent thin-cap neoatheroma is more prevalent, is distributed more diffusely across the stented segment, and is associated with increased periprocedural myocardial infarction in DES compared with bare-metal stents. These findings support NA as a mechanism for late DES failure.
Division of Cardiology, Mount Sinai School of Medicine, New York, NY.
Ziad A
ZA
Ali
Tomasz
T
Roleder
Jagat
J
Narula
Bibhu D
BD
Mohanty
Usman
U
Baber
Jason C
JC
Kovacic
Gary S
GS
Mintz
Fumiyuki
F
Otsuka
Stephen
S
Pan
Renu
R
Virmani
Samin K
SK
Sharma
Pedro
P
Moreno
Annapoorna S
AS
Kini
D000368:Aged; D019917:Blood Vessel Prosthesis Implantation; D054855:Drug-Eluting Stents / Q000009:adverse effects / Q000706:statistics & numerical data*; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D050356:Lipid Metabolism / Q000187:drug effects; D008297:Male; D008670:Metals; D008875:Middle Aged; D064847:Multimodal Imaging; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology; D058226:Plaque, Atherosclerotic / Q000175:diagnosis* / Q000453:epidemiology* / Q000209:etiology; D011183:Postoperative Complications / Q000175:diagnosis* / Q000453:epidemiology*; D015995:Prevalence; D019265:Spectroscopy, Near-Infrared; D041623:Tomography, Optical Coherence; D018084:Ultrasonography, Interventional
D008670:Metals
atherosclerosis; coronary restenosis; percutaneous coronary intervention