Clinical investigations: interventional cardiology
Effect of plaque debulking before stent implantation on in-stent neointimal proliferation: A serial 3-dimensional intravascular ultrasound study

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Abstract

Background

Recent intravascular ultrasound (IVUS) studies have suggested that plaque burden has a role in promoting intimal hyperplasia after stenting. We report on volumetric assessments of in-stent neointimal formation with 3-dimensional IVUS analysis, comparing directional coronary atherectomy (DCA) plus stenting (DCA/stenting) to stenting without DCA.

Methods

Twenty-four patients (24 lesions) treated with DCA before stenting were matched to 24 patients (24 lesions) receiving stenting without DCA. All stents were a single Multilink stent. In both groups, serial IVUS was performed before and after intervention and during the 6-month follow-up period. The arterial segments that were analyzed with a computer-based contour detection program were the same as the stented segments analyzed on serial studies. These measurements were obtained: (1) lumen volume (LV), (2) stent volume (SV), (3) vessel volume (VV), (4) in-stent neointimal volume (ISV) calculated as SV-LV, and (5) percent in-stent neointimal volume (%ISV) calculated as ([SV-LV]/SV) × 100.

Results

Baseline characteristics of the 2 groups were similar. After intervention, both groups achieved similar LV (140.0 mm3 DCA/stenting vs 135.2 mm3 stenting alone). However, the follow-up ISV and %ISV were significantly smaller in the DCA/stenting group (19.6 ± 12.2 mm3 DCA/stenting vs 44.6 ± 29.5 mm3 stenting alone; P = .00040; 15.3% ± 10.6% DCA/stenting vs 31.5% ± 17.7% stenting alone; P = .00040). Consequently, the DCA/stenting group showed a significantly greater follow-up LV (121.0 ± 51.5 mm3 DCA/stenting vs 91.5 ± 26.7 mm3 stenting alone; P = .016).

Conclusions

Plaque removal with DCA before stenting inhibits in-stent neointimal hyperplasia.

Section snippets

Study population and design

From January 2000 through January 2001, 24 patients (with 24 lesions) treated with DCA before stenting were enrolled according to these criteria: (1) successful treatment with DCA before a single Multilink stent (Guidant, Santa Clara, Calif) implantation; (2) the availability of high-quality, automated pullback IVUS images identifying lumen, stent, and media-adventitia borders throughout the length of the lesion; (3) the same arterial segments documented on serial IVUS studies (pre-procedure,

Patient characteristics

Baseline clinical and procedural characteristics are described in Table I. No statistically significant differences between the 2 groups were observed in patient characteristics and lesion characteristics, including pre-procedural QCA data.

Procedure performance

In the DCA/stenting group, the cut number was 22 ± 11, and the maximum balloon pressure during cutting was 34 ± 10 psi. Final balloon size was similar in both groups. However, the incidence of adjunctive balloon inflation was significantly higher (71% vs 17%;

Discussion

The major finding of this study was that plaque removal with DCA resulted in smaller in-stent neointimal proliferation after stent implantation than stenting performed without DCA.

Few IVUS studies, especially for 3-dimensional IVUS, are available that show the positive impact of DCA followed by stent implantation on in-stent neointimal proliferation. However, our findings are consistent with previous observations that provide indirect evidence that debulking with DCA before stenting reduces

References (23)

Cited by (9)

  • Coronary ischemia and percutaneous intervention

    2010, Cardiovascular Pathology
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    The device is advanced to an area of atherosclerosis followed by shaving of the plaque with contents collected in the device nose cone [35]. The effect of an IVUS-directed and aggressive technique of DCA on the vascular endothelium was evaluated by Takeda et al. [36] using IVUS. In 24 lesions treated with DCA prior to stent placement, there was a significant decrease in the neointimal volume within the stent (i.e., in-stent neointimal volume) compared with lesions treated with stenting alone.

  • Coronary Interventional Devices: Balloon, Atherectomy, Thrombectomy and Distal Protection Devices

    2006, Cardiology Clinics
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    On the other hand, high-pressure coronary stent implantation in postmortem histopathologic studies has been shown to cause arterial medial disruption, break in internal elastic lamina, or lipid core penetration by stent struts and may induce increased arterial inflammation associated with increased neointimal growth (Fig. 1) [5]. Studies using intravascular ultrasound (IVUS) have suggested that neointimal area was predicted by the degree of underlying plaque burden (plaque area) before percutaneous coronary intervention (PCI) and the minimal lumen area achieved after PCI [6]. Prati and colleagues [7] demonstrated with IVUS analysis that late loss (degree of internal hyperplasia) has a direct correlation with the amount of residual plaque burden after stent implantation, which suggests that debulking before stenting might reduce restenosis.

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