In-Stent Restenosis Progression in Human Superficial Femoral Arteries: Dynamics of Lumen Remodeling and Impact of Local Hemodynamics

Monika Colombo,Claudio Chiastra,Scott Berceli,Diego Gallo,Stefano Casarin,Francesco Migliavacca,Federica Ninno,Yong He,Jared M Rozowsky,Anna Corti

doi:10.1007/s10439-021-02776-1

Abstract

In-stent restenosis (ISR) represents a major drawback of stented superficial femoral arteries (SFAs). Motivated by the high incidence and limited knowledge of ISR onset and development in human SFAs, this study aims to (i) analyze the lumen remodeling trajectory over 1-year follow-up period in human stented SFAs and (ii) investigate the impact of altered hemodynamics on ISR initiation and progression. Ten SFA lesions were reconstructed at four follow-ups from computed tomography to quantify the lumen area change occurring within 1-year post-intervention. Patient-specific computational fluid dynamics simulations were performed at each follow-up to relate wall shear stress (WSS) based descriptors with lumen remodeling. The largest lumen remodeling was found in the first post-operative month, with slight regional-specific differences (larger inward remodeling in the fringe segments, p < 0.05). Focal re-narrowing frequently occurred after 6 months. Slight differences in the lumen area change emerged between long and short stents, and between segments upstream and downstream from stent overlapping portions, at specific time intervals. Abnormal patterns of multidirectional WSS were associated with lumen remodeling within 1-year post-intervention. This longitudinal study gave important insights into the dynamics of ISR and the impact of hemodynamics on ISR progression in human SFAs.

Highlights

Superficial femoral arteries (SFAs) are atherosclerosis prone.[21]
Two biomechanical factors are deemed to promote in-stent restenosis (ISR): (i) the arterial wall injury provoked by the endovascular procedure,[31] which contributes to ISR initiation, and (ii) the altered local hemodynamics immediately after stenting and during the entire post-operative period,[27] stimulating both ISR initiation and progression
Patient-specific computational fluid dynamics (CFD) simulations were performed at multiple follow-ups to elucidate the possible link between altered hemodynamics and ISR progression

Summary

Introduction

Superficial femoral arteries (SFAs) are atherosclerosis prone.[21] Among the percutaneous approaches to treat atherosclerotic SFAs, the implantation of selfexpanding stents is one of the preferred solutions.[26]. In-stent restenosis (ISR), caused by excessive neointima growth and unfavorable inward remodeling, represents a major drawback.[32]. The incidence of ISR in this vascular region ranges from 15% to 32%, with a peak between 9 and 15 months after intervention.[19] Besides the common clinical promoters, such as diabetes and age,[14] some conditions, including vessel tortuosity,[22] device length,[14] stent overlapping,[34] and biomechanical factors have been identified as concurrent drivers of ISR. Two biomechanical factors are deemed to promote ISR: (i) the arterial wall injury provoked by the endovascular procedure,[31] which contributes to ISR initiation, and (ii) the altered local hemodynamics immediately after stenting and during the entire post-operative period,[27] stimulating both ISR initiation and progression

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Conclusion