Stent Malapposition After Sirolimus-Eluting and Bare-Metal Stent Implantation in Patients with ST-Segment Elevation Myocardial InfarctionAcute and 9-Month Intravascular Ultrasound Results of the MISSION! Intervention Study
Bas L. van der Hoeven, MD*,
Su-San Liem, MD*,
Jouke Dijkstra, MSc ,
Sandrin C. Bergheanu, MD*,
Hein Putter, MSc ,
M. Louisa Antoni, MD*,
Douwe E. Atsma, MD*,
Marianne Bootsma, MD*,
Katja Zeppenfeld, MD*,
J. Wouter Jukema, MD*,
Martin J. Schalij, MD*,*
* Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
Department of Medical Statistics and Bio-Informatics, Leiden University Medical Center, Leiden, the Netherlands
Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands.
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Figure 2 Change of EEM and P&M CSA During the Follow-Up Period for All Individual SM Sites
(A) Bare-metal stent (BMS); (B) sirolimus-eluting stent (SES). The stent malapposition (SM) sites are categorized as resolved, persistent, or acquired SM. Delta ( ) denotes change (follow-up minus post-procedure). (A) BMS: Most of the acute SM sites (resolved and persistent) are located above the x axis, indicating an increase in the plaque and media (P&M) cross-sectional area (CSA) during the follow-up period. Acquired SM sites are very rare after BMS implantation. (B) SES: The external elastic membrane (EEM) and P&M CSA are virtually unchanged in most persistent SM sites. Acquired SM sites are mostly located around the positive x axis, indicating that positive remodeling (enlargement of the EEM CSA, while the P&M CSA remains virtually unchanged) is the mechanism of development of SM in these sites. In a minority of sites, plaque reduction (decrease of the P&M CSA, while the EEM CSA remains virtually unchanged) plays a role.
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Figure 3 Mechanism of Change in Lumen CSA During the Follow-Up Period
(A) BMS; (B) SES. Delta () denotes change (follow-up minus post-procedure). (A) BMS: Changes of the lumen CSA are predominantly determined by changes in P&M CSA, which is positive in the majority of sites. Most likely this is due to neointimal growth. Clearly, remodeling (mostly negative) plays a small role in change of the lumen CSA. (B) SES: Change of the lumen CSA is mainly caused by remodeling after SES implantation, either negative (below x axis) or positive (above x axis). The P&M CSA remains virtually unchanged in most SM sites. Some SM sites demonstrate a clear reduction in P&M CSA, which may be due at least in part to resolution of thrombus behind the stent. Abbreviations as in Figure 2.
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Figure 4 Examples of the Mechanism of Resolved and Acquired SM
The green circle indicates the EEM and the red circle the lumen contour. Delta () denotes change (follow-up minus post-procedure). (A) Resolved proximal edge SM due to increase of plaque burden and some negative remodeling. (Stent CSA: 10.7 mm2, lumen behind stent [LBS] CSA: 5.7 mm2, EEM CSA: –2.1 mm2, P&M CSA: 4.9 mm2, lumen CSA: –7.0 mm2). (B) Acquired body SM because of positive remodeling. (Stent CSA: 6.1 mm2, LBS CSA: 7.0 mm2, EEM CSA: 7.1 mm2, P&M CSA: 0.1 mm2, lumen CSA: 7.0 mm2). (C) Acquired body SM because of plaque reduction. (Stent CSA: 8.6 mm2, LBS CSA: 3.3 mm2, EEM CSA: 0.2 mm2, P&M CSA: 3.2 mm2, lumen CSA: 3.3 mm2). Abbreviations as in Figure 2.
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