Is Stent Underexpansion the Main Cause of In-Stent Restenosis after Sirolimus-Eluting Stent Implantation?: An Intravascular Ultrasound Study

Abstract

Background and Objectives:Intravascular ultrasound (IVUS) can be useful for assessing the causes of in-stent restenosis (ISR) after sirolimus-eluting stent (SES) implantation. We used IVUS to evaluate the causes of ISR after SES implantation. Subjects and Methods:SES implantation was performed in 502 patients with 670 coronary lesions. Of these patients, 27 patients had angiographic ISR in 28 lesions. We evaluated the patterns of ISR and we wanted to elucidate the possible mechanism of ISR after SES implantation with using IVUS analysis. Results:The ISR pattern was focal in 26 lesions, and diffuse in 2 lesions, including 1 total occlusion. When analyzing the 21 IVUS-applicable lesions, stent underexpansion [the minimal stent cross-sectional area (CSA) was <5 mm and it was <4.5 mm in the cases of small coronary arteries (reference vessel diameter <2.8 mm)] was observed in 10 lesions (48%). Stent fracture (defined as non-visualization of the struts on IVUS at the restenotic segments) and edge restenosis was identified in the 3 (14%) and 3 lesions (14%), respectively. Except for edge stenosis, stent underexpansion was observed in 55% of the intra-stent restenotic lesions and it was more prominent in the small coronary arteries (7/8 small coronary artery lesions). Stent underexpansion, stent fracture or edge restenosis were not related to the 7 ISR lesions (33%) in which profound intimal hyperplasia within the stent occurred. Conclusion:Our observation of ISR after SES implantation with using IVUS showed that most ISR lesions have mechanical problems, especially stent underexpansion. However, one third of the ISR lesions were associated with profound intimal hyperplasia within the stent. (Korean Circulation J 2007;37:58-63)