The contribution of “mechanical” problems to in-stent restenosis: An intravascular ultrasonographic analysis of 1090 consecutive in-stent restenosis lesions

doi:10.1067/mhj.2001.119613

American Heart Journal

Volume 142, Issue 6, December 2001, Pages 970-974

https://doi.org/10.1067/mhj.2001.119613 Get rights and content

Abstract

Objectives Serial intravascular ultrasonographic (IVUS) studies have shown that in-stent restenosis is the result of intimal hyperplasia (IH). However, routine preintervention IVUS imaging has suggested that many restenotic stents were inadequately deployed. The purpose of this IVUS study was to determine the incidence of mechanical problems contributing to in-stent restenosis (ISR). Methods Between April 1994 and June 2000, 1090 patients with ISR were treated at the Washington Hospital Center. All underwent preintervention IVUS imaging. IVUS measurements included proximal and distal reference lumen areas and diameters; stent, minimum lumen, and IH (stent minus lumen) areas; and IH burden (IH/stent area). Results In 49 ISR lesions (4.5%), there were morphologic findings that contributed to the restenosis. These were termed mechanical complications. Examples include (1) missing the lesion (eg, an aorto-ostial stenosis), (2) stent “crush,” and (3) having the stent stripped off the balloon during the implantation procedure. Excluding mechanical complications, stent underexpansion was common. In 20% of the ISR cases the stents had a cross-sectional area (CSA) at the site of the lesion <80% of the average reference lumen area. Twenty percent of lesions had a minimum stent area <5.0 mm² and an additional 18% had a minimum stent area of 5.0 to 6.0 mm². Twenty-four percent of lesions had an IH burden <60%. Conclusion Mechanical problems related to stent deployment procedures contribute to a significant minority of ISR lesions (approximately 25%). (Am Heart J 2001;142:970-4.)

Section snippets

Patient population

Between April 1994 and June 2000, 1090 patients with ISR were treated at the Washington Hospital Center. All underwent preintervention IVUS imaging. This includes patients enrolled in various brachytherapy protocols as well as patients referred for coronary artery bypass surgery. ISR lesion location was left main (1%), left anterior descending (30%), left circumflex (21%), right coronary artery (30%), and saphenous vein graft (18%). Patient demographic data are shown in Table I.

. Patient

Mechanical complications

Preinterventional qualitative IVUS analysis of 1090 ISR lesions shown that in 49 ISR lesions (4.5%), there were morphologic findings that contributed to the restenosis. These were termed mechanical complications. Examples include (1) missing the lesion (eg, an aorto-ostial stenosis, n = 12 cases), (2) a “crushed” stent (n = 27), or (3) a stent getting stripped off the balloon (n = 10) during the implantation procedure (Figure 1).

. An example of a crushed stent is shown. Note that the distal half

Discussion

We undertook this retrospective analysis to confirm our clinical suspicion that in a significant number of patients with ISR there was a mechanical problem with the stent.

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Interventional CardiologyThe contribution of “mechanical” problems to in-stent restenosis: An intravascular ultrasonographic analysis of 1090 consecutive in-stent restenosis lesions☆

Abstract

Section snippets

Patient population

Mechanical complications

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Interventional Cardiology
The contribution of “mechanical” problems to in-stent restenosis: An intravascular ultrasonographic analysis of 1090 consecutive in-stent restenosis lesions☆