Atypical “vacuum” inside of neoatherosclerosis long term after DES implantation: Insights from optical coherence tomography

Abstract

Percutaneous coronary intervention (PCI) with stenting is the most widely performed procedure for the treatment of symptomatic coronary artery disease [ [1] Serruys P.W. et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. Benestent Study Group. N. Engl. J. Med. 1994; 331: 489-495 Crossref PubMed Scopus (4365) Google Scholar ], and the technological developments of drug-eluting stents (DES) have reduced the rates of in-stent restenosis and target lesion revascularization of bare-metal stent [ 2 Morice M.C. et al. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N. Engl. J. Med. 2002; 346: 1773-1780 Crossref PubMed Scopus (3859) Google Scholar , 3 Fajadet J. et al. Maintenance of long-term clinical benefit with sirolimus-eluting coronary stents: three-year results of the RAVEL trial. Circulation. 2005; 111: 1040-1044 Crossref PubMed Scopus (216) Google Scholar , 4 Moses J. et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N. Engl. J. Med. 2003; 349: 1315-1323 Crossref PubMed Scopus (4060) Google Scholar , 5 Weiz G. et al. Five-year follow-up after sirolimus-eluting stent implantation: results of the SIRIUS (Sirolimus-Eluting Stent in De-Novo Native Coronary Lesions) trial. J. Am. Coll. Cardiol. 2009; 53: 1488-1497 Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar ]. Clinical and histological studies of DES have confirmed evidence that restenosis is the result of arterial damage with subsequent neointimal tissue proliferation, which was named as “late catch-up” phenomenon [ 6 Grube et al. TAXUS VI final 5-year results: a multicentre, randomised trial comparing polymer-based moderate-release paclitaxel-eluting stent with a bare metal stent for treatment of long, complex coronary artery lesions. EuroIntervention. 2009; 4: 572-577 Crossref PubMed Scopus (58) Google Scholar , 7 Nakazawa et al. Coronary responses and differential mechanisms of late stent thrombosis attributed to first-generation sirolimus- and paclitaxel-eluting stents. J. Am. Coll. Cardiol. 2011; 57: 390-398 Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar ]. The mechanisms behind this DES failure remain complex and multi-factorial. The atherosclerotic changes (neoatherosclerosis) of neointimal layer inside of a restenosis are now thought to be potential mechanisms of DES failure [ [8] Park S.J. et al. In-stent neoatherosclerosis: a final common pathway of late stent failure. J. Am. Coll. Cardiol. 2012; 59: 2051-2057 Abstract Full Text Full Text PDF PubMed Scopus (301) Google Scholar ]. The exact pathogenesis of neoatherosclerosis remains partially unknown, however Yonetsu et al. have shown that the risk factors such as stent >48 months old, DES, cigarette smoking and chronic kidney disease are strongly associated with the formation of neoatherosclerosis, whereas the use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers appears to be protective [ [9] Yonetsu et al. Predictors for neoatherosclerosis: a retrospective observational study from the optical coherence tomography registry. Circ. Cardiovasc. Imaging. 2012; 5: 660-666 Crossref PubMed Scopus (126) Google Scholar ]. We present a case of atypical “vacuum” inside neoatherosclerotic pattern of restenosis after DES implantation where the OCT was used to describe this new report of neoatherosclerosis and to demonstrate probable causes of it.