title: Coronary evaginations are associated with positive vessel remodelling and are nearly absent following implantation of newer-generation drug-eluting stents: an optical coherence tomography and intravascular ultrasound study.
abstract: OBJECTIVE
  The purpose of this study was to assess the occurrence, predictors, and mechanisms of optical coherence tomography (OCT)-detected coronary evaginations following drug-eluting stent (DES) implantation.
  
  
  BACKGROUND
  Angiographic ectasias and aneurysms in stented segments have been associated with a risk of late stent thrombosis. Using OCT, some stented segments show coronary evaginations reminiscent of ectasias.
  
  
  METHODS
  Evaginations were defined as outward bulges in the luminal contour between struts. They were considered major evaginations (MEs) when extending ≥3 mm along the vessel length, with a depth ≥10% of the stent diameter. A total of 228 patients who had sirolimus (SES)-, paclitaxel-, biolimus-, everolimus (EES)-, or zotarolimus (ZES)-eluting stents implanted in 254 lesions, were analysed after 1, 2, or 5 years; and serial assessment using OCT and intravascular ultrasound (IVUS) was performed post-intervention and after 1 year in 42 patients.
  
  
  RESULTS
  Major evaginations occurred frequently at all time points in SES (∼26%) and were rarely seen in EES (3%) and ZES (2%, P = 0.003). Sirolimus-eluting stent implantation was the strongest independent predictor of ME [adjusted OR (95% CI) 9.1 (1.1-77.4), P = 0.008]. Malapposed and uncovered struts were more common in lesions with vs. without ME (77 vs. 25%, P < 0.001 and 95 vs. 20%, P < 0.001, respectively) as was thrombus [49 vs. 14%, OR 7.3 (95% CI: 1.7-31.2), P = 0.007]. Post-intervention intra-stent dissection and protrusion of the vessel wall into the lumen were associated with an increased risk of evagination at follow-up [OR (95% CI): 2.9 (1.8-4.9), P < 0.001 and 3.3 (1.6-6.9), P = 0.001, respectively]. In paired IVUS analyses, lesions with ME showed a larger increase in the external elastic membrane area (20% area change) compared with lesions without ME (5% area change, P < 0.001).
  
  
  CONCLUSIONS
  Optical coherence tomography-detected MEs are a specific morphological footprint of early-generation SES and are nearly absent in newer-generation ZES and EES. Evaginations appear to be related to vessel injury at baseline; are associated with positive vessel remodelling; and correlate with uncoverage, malapposition, and thrombus at follow-up.
authors.affiliation: Thoraxcenter, Erasmus University Medical Centre, Ba583a, 's-Gravendijkwal 230, 3015 CE Rotterdam, Netherlands.
authors.forename: Maria D
authors.initials: MD
authors.lastname: Radu
authors.forename: Lorenz
authors.initials: L
authors.lastname: Räber
authors.forename: Bindu
authors.initials: B
authors.lastname: Kalesan
authors.forename: Takashi
authors.initials: T
authors.lastname: Muramatsu
authors.forename: Henning
authors.initials: H
authors.lastname: Kelbæk
authors.forename: Jungho
authors.initials: J
authors.lastname: Heo
authors.forename: Erik
authors.initials: E
authors.lastname: Jørgensen
authors.forename: Steffen
authors.initials: S
authors.lastname: Helqvist
authors.forename: Vasim
authors.initials: V
authors.lastname: Farooq
authors.forename: Salvatore
authors.initials: S
authors.lastname: Brugaletta
authors.forename: Hector M
authors.initials: HM
authors.lastname: Garcia-Garcia
authors.forename: Peter
authors.initials: P
authors.lastname: Jüni
authors.forename: Kari
authors.initials: K
authors.lastname: Saunamäki
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Serruys
mesh_terms: D003327:Coronary Disease / Q000473:pathology*; D003331:Coronary Vessels / Q000473:pathology*; D054855:Drug-Eluting Stents; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D065228:Non-Randomized Controlled Trials as Topic; D011446:Prospective Studies; D041623:Tomography, Optical Coherence; D050257:Tubulin Modulators / Q000008:administration & dosage; D018084:Ultrasonography, Interventional; D066253:Vascular Remodeling / Q000187:drug effects
chemical_list: D050257:Tubulin Modulators
keywords: Coronary evaginations; Early-generation drug-eluting stents; Intravascular ultrasound; Malapposition; Newer-generation drug-eluting stents; Optical coherence tomography; Positive remodelling; Uncovered stent struts