Coronary Artery Disease
Does the specific intravascular ultrasound criterion used to optimize stent expansion have an impact on the probability of stent restenosis?

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Abstract

Intravascular ultrasound (IVUS) imaging has been used to optimize stent implantation in coronary arteries, but the criteria used were chosen on an empiric basis. The aim of this study was to determine whether any of these criteria have an independent role in predicting the probability of freedom from restenosis. The study population consisted of 425 patients (496 lesions) who underwent angiographically successful IVUS-guided stenting. Five IVUS criteria were studied: (1) intrastent minimal lumen cross-sectional area (ISMLCSA) ≥9 mm2; (2) ISMLCSA (≥9 mm2 and ≥80% of average reference lumen cross-sectinla area [CSA]); (3) ISMLCSA ≥90% of average reference lumen CSA; (4) ISMLCSA ≥90% of distal reference lumen CSA; and (5) ISMLCSA ≥55% of average reference vessel CSA. These criteria were met in 33%, 29%, 68%, 82%, and 69% of lesions, respectively. Angiographic follow-up was performed in 335 of 421 eligible patients (80%) at 5.3 ± 2.7 months. An absolute ISMLCSA ≥9 mm2 was associated with the lowest restenosis, but this criterion was primarily achieved in large vessels. The only criterion that was associated with higher probability of freedom from restenosis independently from vessel size was an ISMLCSA ≥55% of average reference vessel CSA. Therefore, when IVUS is used to guide stent implantation an effort should be made to achieve the largest lumen safely possible. An ISMLCSA ≥55% of the average reference vessel CSA seems to be the most appropriate criterion in terms of frequency of achievement and in terms of increasing the probability of freedom from restenosis.

Section snippets

Patient population

From March 1993 until June 1995, 425 patients presented with 496 nonostial lesions in native coronary arteries and underwent angiographically successful Palmaz-Schatz stent implantation. All these patients underwent IVUS interrogation and had high quality images that allowed assessment of the stented segment and the proximal and distal reference. In all, 335 of 421 eligible patients (80%) with 390 of 490 lesions (80%) underwent angiographic follow-up at 5.3 ± 2.7 months. All eligible patients

Patient’s characteristics and factors associated with achieving various IVUS criteria

Patient’s clinical and angiographic characteristics are listed in Table I, Stenting indications were elective in 413 lesions (82%), suboptimal angioplasty in 60 lesions (12%), and threatened closure in 33 lesions (6%). The angiographic and procedural variables associated with each specific criterion are listed in Table II. and the IVUS measurements are listed in Table III. An ISMLCSA ≥9 mm2 and an ISMLCSA (≥9 mm2 and ≥80% of average reference lumen CSA) were achieved in a few patients with

Discussion

The major findings of this study are that (1) there is large variability in the frequency of achieving various IVUS criteria based on differences in vessel size, plaque burden, and balloon-to-artery ratio; (2) achieving an ISMLCSA ≥90% of reference lumen CSA (average or distal) did not lead to a reduction in restenosis; (3) achieving an ISMLCSA ≥9 mm2 was associated with a low restenosis rate, but this criterion was primarily achieved in large vessels; and (4) achieving an ISMLCSA ≥55% of

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