Upcoming events

Optical coherence tomography-based evaluation of in-stent neoatherosclerosis in lesions with more than 50% neointimal cross-sectional area stenosis

Selected in EuroIntervention by S. Brugaletta

References

Authors

Lee S-Y, Shin D-H, Mintz G, Kim J-S, Kim B-K, Ko Y-G, Choi D, Jang Y, Hong M-K

Reference

EuroIntervention 2013;9:945-951

Published

December 2013

Link

Access article

Aims

To use optical coherence tomography (OCT) to evaluate the time course, risk factors, and clinical implication of in-stent neoatherosclerosis.

Methods and results

The neointimal characteristics of 152 lesions, 128 drug-eluting stents (DESs) and 24 bare metal stents (BMSs), with >50% percent cross-sectional area (CSA) neointimal stenosis were evaluated. Neoatherosclerosis was defined as neointima with presence of lipid or calcification. Neoatherosclerosis was observed in 54 lesions (35.5%, 35 DESs and 19 BMSs). Median time to follow-up was 70.7 months in lesions with neoatherosclerosis (longer than lesions without neoatherosclerosis [13.4 months, p<0.001]): 58.7 months in DES-treated lesions and 129.5 months in BMS-treated lesions (p<0.001). The optimal cut-off time to pre- dict neoatherosclerosis in DES-treated lesions was 30 months with a sensitivity of 91.4% and a specificity of 72.0% (area under curve: 0.839, 95% confidence interval: 0.764-0.898, p<0.001). Independent risk factors for neoatherosclerosis were stent age, use of first-generation DES and hypertension. Patients with neoathero- sclerosis (versus without neoatherosclerosis) had a higher rate of target lesion revascularisation (92.6% vs. 77.6%, respectively, p=0.018) and stent thrombosis (14.8% vs. 0%, respectively, p<0.001).

Conclusions

Neoatherosclerosis occurred in one-third of stented lesions with >50% percent CSA stenosis of neointima. Late-phase development of neoatherosclerosis might be associated with clinical deterioration of stented lesions.

My Comment

What is known

The phenomenon of atheromatous changes within neo-intimal tissue, namely neo-atherosclerosis, is considered to occur more than five years post BMS implantation. Conversely, previous pathologic studies have reported a more frequent and accelerated occurrence of neo-atherosclerosis in drug-eluting stent (DES)-treated lesions compared to BMS-treated lesions. Detailed in vivo information about neo-atherosclerosis is limited, with small studies conducted in small number of patients. The present OCT study was designed to investigate the time course, risk factors and clinical implication of neo-atherosclerosis in a large number of mostly symptomatic patients with a significant burden of neo-intimal tissue.

Major findings

  • The neo-intimal characteristics of 152 lesions, 128 drug-eluting stents (DESs) and 24 bare metal stents (BMSs), with >50% percent cross-sectional area (CSA) neo-intimal stenosis were evaluated. Neo-atherosclerosis was defined as neointima with presence of lipid or calcification.
  • Neo-atherosclerosis was observed in 54 lesions (35.5%, 35 DESs and 19 BMSs). Median time to follow-up was 70.7 months in lesions with neo-atherosclerosis (longer than lesions without neo-atherosclerosis [13.4 months, p<0.001]): 58.7 months in DES-treated lesions and 129.5 months in BMS-treated lesions (p<0.001).
  • The optimal cut-off time to predict neo-atherosclerosis in DES-treated lesions was 30 months with a sensitivity of 91.4% and a specificity of 72.0% (area under curve: 0.839, 95% confidence interval: 0.764-0.898, p<0.001).
  • Independent risk factors for neo-atherosclerosis were stent age, use of first-generation DES and hypertension. Patients with neo-atherosclerosis (versus without neo-atherosclerosis) had a higher rate of target lesion revascularization (92.6% vs. 77.6%, respectively, p=0.018) and stent thrombosis (14.8% vs. 0%, respectively, p<0.001).

My Comments

This paper describes the largest series of patients who develop neo-atherosclerosis in a metallic stent previously implanted with OCT analysis. It shows that neo-atherosclerosis occurred in one-third of stented lesions and it is associated with stent age, use of first-generation DES and hypertension. The definition used by the authors for defining neo-atherosclerosis as compared to neo-intima is interesting, because it could be applied in an “expert consensus”. In addition, OCT seems to have an important role in understanding the mechanism of stent failure (stent under-expansion, neo-atherosclerosis, etc) and potentially driving the therapeutic option for in-stent restenosis. With this regards, it would be interesting to know how many readers already have OCT in their “internal” guidelines for in stent-restenosis treatment.

No comments yet!