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A Volumetric Intravascular Ultrasound Comparison of Early Drug-Eluting Stent Thrombosis Versus Restenosis

Xuebo Liu, MD^_*,, Hiroshi Doi, MD, PhD^_*,, Akiko Maehara, MD^_*,,_*, Gary S. Mintz, MD^_*,, Jose de Ribamar Costa, Jr, MD^_*,, Koichi Sano, MD, PhD^_*,, Giora Weisz, MD^_*,, George D. Dangas, MD, PhD^_*,, Alexandra J. Lansky, MD^_*,, Edward M. Kreps, MD^_*,, Michael Collins, MD^_*,, Martin Fahy, MSc, Gregg W. Stone, MD^_*,, Jeffrey W. Moses, MD^_*,, Martin B. Leon, MD^_*,, Roxana Mehran, MD^_*,

^_* Columbia University Medical Center, New York, New York
Cardiovascular Research Foundation, New York, New York

^_* Reprint requests and correspondence: Dr. Akiko Maehara, Cardiovascular Research Foundation, 111 East 59th Street, 12th floor, New York, New York 10022 (Email: amaehara{at}crf.org).

Objectives: We compared intravascular ultrasound findings of drug-eluting stent (DES)–treated lesions that developed thrombosis versus in-stent restenosis (ISR).

Background: Stent underexpansion is a predictor of both DES thrombosis and ISR. However, all underexpanded DES may not be equal.

Methods: Intravascular ultrasound findings from 20 definite DES thrombosis patients (representing all definite thromboses from 1,407 consecutive DES patients undergoing intravascular ultrasound imaging) were compared with 50 risk-factor-balanced ISR patients with no evidence of stent thrombosis and 50 risk-factor-balanced "no-event" patients with neither thrombosis nor ISR.

Results: Minimum stent area (3.9 ± 1.0 mm² vs. 5.0 ± 1.7 mm², p = 0.008), mean stent area (5.3 ± 1.0 mm² vs. 7.2 ± 2.0 mm², p = 0.001), and both focal (55.4 ± 13.2% vs. 74.9 ± 19.9%, p < 0.001) and diffuse stent expansion (77.4 ± 19.3% vs. 109.5 ± 23.1%, p < 0.001) were significantly smaller in the stent thrombosis group versus ISR and in both groups versus the "no-event" group. Minimum stent area <4.0 mm² (65% vs. 32%, p = 0.01) or <5.0 mm² (85% vs. 52%, p = 0.01) was more common in the stent thrombosis versus the ISR group and in both groups vs. "no-event" patients; and the relative length of the stent area <5 mm² was greatest in the stent thrombosis group (36.6 ± 37.7%), intermediate in the ISR group (22.8 ± 35.6%), and least in the "no-event" group (10.9 ± 26.4%), p = 0.04. In the stent thrombosis group, the minimum stent area site occurred in the proximal stent segment in 50% versus 24% in the ISR group (p = 0.03). There were no differences in edge dissection, stent fracture, or stent-vessel-wall malapposition among the groups.

Conclusions: The DES-treated lesions that develop thrombosis or restenosis are often underexpanded, but underexpansion associated with thrombosis is more severe, diffuse, and proximal in location.

Key Words: intravascular ultrasound • stent thrombosis • in-stent restenosis • stent expansion

Abbreviations and Acronyms   CSA = cross-sectional area   DES = drug-eluting stent(s)   EEM = external elastic membrane   ISR = in-stent restenosis   IVUS = intravascular ultrasound   MSA = minimum stent area

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