Predictors for functionally significant in-stent restenosis: an integrated analysis using coronary angiography, IVUS, and myocardial perfusion imaging.
OBJECTIVE
The aim of this study was to assess the clinical and morphological predictors for functionally significant in-stent restenosis (ISR).


BACKGROUND
Although they have been studied de novo in native coronary artery lesions, the relationships between clinical and morphological characteristics and the hemodynamic significance of ISR are not well understood.


METHODS
In 175 patients with ISR of a single coronary artery (angiographic stenosis >50%), we compared quantitative coronary angiography and intravascular ultrasound (IVUS) with stress myocardial single-photon emission computed tomography (SPECT). A positive SPECT was a reversible perfusion defect in the territory of the ISR artery.


RESULTS
Overall, 103 (59%) patients had a positive SPECT. In-segment IVUS minimal lumen area (MLA) was significantly smaller in lesions with positive SPECT compared with negative SPECT (1.7 ± 0.5 mm(2) vs. 2.4 ± 0.8 mm(2), p < 0.001). Stent underexpansion (minimal stent area <5.0 mm(2)) was more common in the positive SPECT group than in the negative SPECT group (52% vs. 32%, p = 0.010). A positive SPECT was seen in 54% (65 of 121) of focal ISR lesions compared with 70% (38 of 54) of multifocal or diffuse ISR lesions as assessed by IVUS (p = 0.039). Independent determinants for a positive SPECT were diabetes (odds ratio [OR]: 2.41; 95% confidence interval [CI]: 1.02 to 5.68; p = 0.046), in-segment angiographic diameter stenosis (OR: 1.06; 95% CI: 1.03 to 1.09; p < 0.001), in-segment IVUS-MLA (OR: 0.30; 95% CI: 0.14 to 0.63; p = 0.001), stent underexpansion (minimal stent area <5.0 mm(2)), (OR: 2.91; 95% CI: 1.19 to 7.07; p = 0.019), proximal location of the IVUS-MLA (OR: 4.62; 95% CI: 1.75 to 12.18; p = 0.002), and a multifocal or diffuse ISR pattern (OR: 2.50; 95% CI: 0.99 to 6.28; p = 0.050). An in-segment angiographic diameter stenosis ≥69.5% (72% sensitivity, 74% specificity, area under the curve = 0.793) and an IVUS-MLA ≤1.9 mm(2) (67% sensitivity, 75% specificity, area under the curve = 0.756) best predicted a positive SPECT; however, the overall diagnostic accuracies were only 73% and 70%, respectively.


CONCLUSIONS
In lesions with ISR, neither angiography nor IVUS accurately predicted an abnormal SPECT.
Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
Soo-Jin
SJ
Kang
Young-Rak
YR
Cho
Gyung-Min
GM
Park
Jung-Min
JM
Ahn
Seung-Bong
SB
Han
Jong-Young
JY
Lee
Won-Jang
WJ
Kim
Duk-Woo
DW
Park
Seung-Whan
SW
Lee
Young-Hak
YH
Kim
Cheol Whan
CW
Lee
Seong-Wook
SW
Park
Gary S
GS
Mintz
Seung-Jung
SJ
Park
D000368:Aged; D016009:Chi-Square Distribution; D017023:Coronary Angiography; D003326:Coronary Circulation; D023903:Coronary Restenosis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology; D003331:Coronary Vessels / Q000000981:diagnostic imaging / Q000503:physiopathology; D005260:Female; D006439:Hemodynamics; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging / Q000379:methods*; D015999:Multivariate Analysis; D055414:Myocardial Perfusion Imaging; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects* / Q000295:instrumentation*; D011237:Predictive Value of Tests; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents; D015899:Tomography, Emission-Computed, Single-Photon; D018084:Ultrasonography, Interventional
%IH; CI; DS; IH; ISR; IVUS; MLA; MLD; NPV; OR; PPV; SPECT; confidence interval; diameter stenosis; in-stent restenosis; intimal hyperplasia; intravascular ultrasound; minimal lumen area; minimal lumen diameter; myocardial perfusion imaging; negative predictive value; odds ratio; percentage of intimal hyperplasia; positive predictive value; single-photon emission computed tomography