Mechanism of Edge Restenosis After Drug-Eluting Stent Implantation

Kim, Yun Gi; Oh, Il Young; Kwon, Yoo Wook; Han, Jung Kyu; Yang, Han Mo; Park, Kyung Woo; Lee, Hae Young; Kang, Hyun–Jae; Koo, Bon Kwon; Kim, Hyo Soo

doi:10.1253/circj.cj-12-1259

Cited by 26 publications

(7 citation statements)

References 28 publications

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“…We reckon that sufficient plaque debulking and DCB angioplasty are effective to obtain large lumen area and to inhibit neointimal hyperplasia which is the main cause of restenosis in nonstented vessels. On the other hand, several mechanisms of stent edge restenosis have been reported including negative remodeling, mechanical injury at stent edge due to hinge motion, and local changes in shear stress [11][12][13]. In particular, all the TLR cases in the current study of stent edge restenosis at the LAD ostium had a low %PA following DCA.…”

Section: Discussionmentioning

confidence: 59%

Stentless Strategy by Drug-Coated Balloon Angioplasty following Directional Coronary Atherectomy for Left Main Bifurcation Lesion

Kobayashi

Yamawaki

Mori

et al. 2021

Journal of Interventional Cardiology

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Aims. We aimed to evaluate the efficacy of stentless strategy by drug-coated balloon (DCB) angioplasty following directional coronary atherectomy (DCA) for left main (LM) bifurcation lesions. Methods. A total of 38 patients who underwent DCB angioplasty following DCA for LM bifurcation lesions were retrospectively enrolled. The primary endpoint was target vessel failure (TVF) at 12 months. Secondary endpoints included procedure-related major events during the hospitalization, major adverse cardiac events at 12 months, ischemia-driven target lesion revascularization (TLR) at 12 months, and bleeding complications defined as the Bleeding Academic Research Consortium criteria ≥2 at 12 months. Results. Among these 38 lesions, 31 lesions were de novo LM bifurcation lesions and 7 lesions were stent edge restenosis at the left anterior descending (LAD) ostium. The mean % plaque area (%PA) after DCA was 44.0 ± 7.4%. TVF at 12 months occurred in 1 lesion (3.2%) of de novo LM bifurcation lesion and in 3 lesions (42.9%) of stent edge restenosis at the LAD ostium. All events of TVF were ischemia-driven TLR by percutaneous coronary intervention. Among 4 TLR cases, %PA after DCA was high (55.9%) in the de novo LM bifurcation lesions; on the other hand, %PA after DCA was low (42.4%, 38.7%, and 25.7% in the 3 cases) in stent edge restenosis at the LAD ostium. No procedure-related major events were observed during hospitalization. There was no cardiac death, no myocardial infarction, no coronary artery bypass grafting, and no bleeding complications at 12 months. Conclusions. Stentless strategy by DCB angioplasty following DCA for de novo LM bifurcation lesions resulted in acceptable outcomes. On the other hand, its efficacy was limited for stent edge restenosis at the LAD ostium even after aggressive debulking by DCA.

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Section: Discussionmentioning

confidence: 59%

Stentless Strategy by Drug-Coated Balloon Angioplasty following Directional Coronary Atherectomy for Left Main Bifurcation Lesion

Kobayashi

Yamawaki

Mori

et al. 2021

Journal of Interventional Cardiology

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“…For instance, tortuous lesions are a risk factor for restenosis or stent fracture after stent implantation [ [31][32][33]. Moreover, SER can occur stent implantation due to physical stress at the stent edge segment in tortuous vessels [4]. Thus, SER may be associated with tortuous vessels.…”

Section: Discussionmentioning

confidence: 99%

“…Stent edge restenosis (SER) is a type of ISR observed at the edge of the stent and identified as the prevailing limitation of ISR after stent implantation. It has been reported that the mechanism of SER was related to vessel injury by ballooning or stent implantation, the residual plaque, and the small lumen area in the stent edge segments [4][5][6][7]. In addition, mechanical stresses due to hinge motion are risk factors for SER incidents [8].…”

Section: Introductionmentioning

confidence: 99%

Drug-coated balloons for the treatment of stent edge restenosis

Nagasaka

Amanai

Ishibashi

et al. 2023

Coronary Artery Disease

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Background Drug-coated balloon (DCB) is a device for treating patients with in-stent restenosis; however, there are scant data on its efficacy for stent edge restenosis (SER). This study aimed to investigate the clinical outcomes of DCB use for treating SER compared with new-generation drug-eluting stent (DES) implantation. Method From December 2013 to January 2019, patients who underwent DES implantation or DCB for SER were enrolled. Clinical outcomes were analyzed, and propensity score with matching was conducted. The primary outcome was target-vessel revascularization (TVR). The secondary outcomes were the incidence of all-cause mortality, major adverse cardiovascular events (MACE), and target lesion revascularization (TLR). Result A total of 291 patients with SER were included: 160 were treated with DCB, and 131 with new-generation DES. DCB treatment for SER treatment was associated with a lower risk of TVR than DES [hazard ratio, 0.549; 95% confidence interval (CI), 0.339–0.891] at a median follow-up of 1080 days (interquartile range; 729–1080 days). Propensity score matching (PSM) was performed to adjust for baseline clinical and lesion characteristics. After PSM, no significant difference in the risk of TVR was observed (hazard ratio, 0.965; 95% CI, 0.523–1.781). Similarly, the risk for all-cause death (hazard ratio, 0.507; 95% CI, 0.093–2.770), MACE (hazard ratio: 0.812; 95% CI, 0.451–1.462), and TLR (hazard ratio: 0.962; 95% CI, 0.505–1.833) were comparable between the two groups. Conclusion DCB treatment efficacy for SER was similar to that of new-generation DES after PSM. DCB is a significant alternative to obtain comparable results with new-generation DES for the treatment of SER.

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“…It has been suggested that this arises from mechanical injury and chronic local inflammation at the stent edge induced by hinge motion between stented and unstented segments of the vessel with every heart contraction. 8 It has also been suggested that straightening of a curved artery upon stenting changes the WSS distribution at the stent edge, leading to endothelial dysfunction and edge restenosis. 19 Moreover, finite element analysis of a curved bifurcation model suggested that the straightening effect is attenuated by making the stent more flexible, thereby reducing the mechanical stress to the artery, in particular at the distal end of the stent and the side branch ostium.…”

Section: Discussionmentioning

confidence: 99%

“…[3][4][5] This high restenosis rate in bifurcation lesions could stem from chronic inflammation due to continuous mechanical stress from the stent on the artery. [6][7][8] Alternatively, restenosis could be caused by the delay in re-endothelialization and endothelial dysfunction due to flow disturbances and the concomitant change in wall shear stress (WSS) on endothelial cells (ECs). 9 In either case, stent flexibility is likely a key contributing factor because a rigid stent would straighten the artery, increasing mechanical stress and the change of WSS.…”

Section: Introductionmentioning

confidence: 99%

<p>Influence of Stent Flexibility on Artery Wall Stress and Wall Shear Stress in Bifurcation Lesions</p>

Sakai¹,

Mori²,

Komatsu³

2020

MDER

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Purpose Stent flexibility can influence clinical outcome, especially in bifurcation lesions. For instance, an overly rigid stent can impose mechanical stress on the artery at the stent edges and alter both arterial geometry and blood flow dynamics in bifurcations. This study investigated the influence of stent flexibility on vessel geometry, histology, wall stress, and blood flow dynamics in arterial bifurcations. Materials and Methods We compared arterial angulation, stenosis, histopathology, simulated wall shear stress (WSS), and simulated blood flow velocity distribution in swine coronary artery bifurcations following placement of the less flexible Multi-link 8 or more flexible Kaname stent (4.1 ± 0.5 vs 1.5 ± 0.1 mN, p < 0.05, t -test). Stents were implanted into six coronary artery bifurcations each using the single-stent crossover technique without side branch strut dilatation. Outcomes were examined after 28 days. Results Implantation of both stents significantly increased site angulation (Multi-link 8: 148° ± 8° to 172° ± 2°, p < 0.05, paired t -test; Kaname: 152° ± 5° to 164° ± 4°, p < 0.05, paired t -test), but the change tended to be greater after Multi-link 8 stent implantation (24° ± 15° vs 11° ± 7°, p = 0.1, t -test), suggesting greater straightening of the bifurcation. The Multi-link 8 stent induced greater neointimal thickness than the Kaname stent (0.53 ± 0.3 mm vs 0.26 ± 0.1 mm, p < 0.05, t -test). The distribution of neointimal hyperplasia following stent implantation as revealed by longitudinal histopathology matched the distribution of WSS simulated using computational fluid dynamics (CFD). The endothelium at low WSS areas exhibited aberrant cell morphology and leukocyte adhesion. A CFD model of a curved bifurcation suggested that the region of low WSS is expanded by artery straightening. Conclusion In bifurcated lesions, stent flexibility influences not only mechanical stress on the artery but also WSS, which may induce local neointimal hyperplasia.

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Mechanism of Edge Restenosis After Drug-Eluting Stent Implantation

Cited by 26 publications

References 28 publications

Stentless Strategy by Drug-Coated Balloon Angioplasty following Directional Coronary Atherectomy for Left Main Bifurcation Lesion

Stentless Strategy by Drug-Coated Balloon Angioplasty following Directional Coronary Atherectomy for Left Main Bifurcation Lesion

Drug-coated balloons for the treatment of stent edge restenosis

<p>Influence of Stent Flexibility on Artery Wall Stress and Wall Shear Stress in Bifurcation Lesions</p>

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