Early Follow-Up Optical Coherence Tomographic Findings of Significant Drug-Eluting Stent Malapposition: Results From the DETECT-OCT Trial

Clinical Implications of Post-Stent Optical Coherence Tomographic Findings: Severe Malapposition and Cardiac Events

OBJECTIVES

This study sought to evaluate the impact of post-stent optical coherence tomography (OCT) findings, including severe malapposition, on long-term clinical outcomes.

BACKGROUND

Suboptimal OCT findings following percutaneous coronary intervention (PCI) are highly prevalent; however, their clinical implications remain controversial.

METHODS

Of the patients registered in the Yonsei OCT registry, a total of 1,290 patients with 1,348 lesions, who underwent OCT immediately post-stenting, were consecutively enrolled for this study. All patients underwent implantation of drug-eluting stents. Post-stent OCT findings were assessed to identify predictors of device-oriented clinical endpoints (DoCE), including cardiac death, target vessel-related myocardial infarction (MI) or stent thrombosis, and target lesion revascularization (TLR). Significant malapposition criteria associated with major safety events (MSE) were also investigated, such as cardiac death, target vessel-related MI, or stent thrombosis.

RESULTS

The median follow-up period was 43.0 months (interquartile range [IQR] 21.4 to 56.0 months). The incidence rates of stent edge dissection, tissue prolapse, thrombus, and malapposition after intervention were not associated with occurrence of DoCE. However, patients with significant malapposition (total malapposition volume [TMV] ≥7.0 mm³] exhibited more frequent MSE. A smaller minimal stent area (MSA) was identified as an independent predictor for DoCE (hazard ratio [HR]: 1.20 [95% confidence interval [CI]: 1.00 to 1.43]; p = 0.045). Malapposition with TMV ≥7.0 mm³ was found to be an independent predictor of MSE (HR: 6.12 [95% CI: 1.88 to 19.95]; p = 0.003). Follow-up OCT at 3, 6, or 9 months after PCI showed that post-stent TMV ≥7.0 mm³ was related to a greater occurrence of late malapposition and uncovered struts.

CONCLUSIONS

Although most suboptimal OCT findings were not associated with clinical outcomes, a smaller MSA was associated with DoCE, driven mainly by TLR, and significant malapposition with TMV ≥7.0 mm³ was associated with more MSE after PCI. (Yonsei OCT [Optical Coherence Tomography] Registry for Evaluation of Efficacy and Safety of Coronary Stenting; Yonsei OCT registry; NCT02099162).

Temporal changes of incomplete stent apposition during early phase after everolimus-eluting stent implantation: serial optical coherence tomography analyses at 2-week and 4-month

The healing process of acute incomplete stent apposition (ISA) in the early phase after stent implantation has not been well understood. We evaluated the temporal changes of ISA during the early phase after everolimus-eluting stent (EES) implantation using serial optical coherence tomography (OCT) analyses. Serial OCT examinations were performed immediately post-stenting and 2-week and 4-month after EES implantation for patients with ST-segment elevation myocardial infarction. At the most proximal cross-section of the implanted stent, the prevalence of ISA and maximum ISA distance were serially evaluated. In 45 patients with ST-segment elevation myocardial infarction, serial OCT analyses at 2-week and 4-month were performed. The prevalence of ISA gradually decreased over time, being 53.3% at baseline, 37.8% at 2-week follow-up, and 11.1% at 4-month follow-up (P < 0.001). The maximum ISA distance also decreased over time (P < 0.001). A receiver-operating curve analysis found that the optimal cut-off values of the baseline ISA distance for predicting persistent ISA at 2-week follow-up and 4-month follow-up were > 140 µm and > 215 µm, respectively. The baseline ISA distance was closely associated with the healing of ISA in the early phase after EES implantation. Maintaining the minimum ISA distance at post-stenting facilitates early phase healing of acute ISA.

Long-term Clinical Outcomes of Drug-Eluting Stent Malapposition

Previous pathologic, intravascular imaging, and clinical studies have investigated the association between adverse cardiac events and stent malapposition, including acute stent malapposition (ASM, that is detected at index procedure) and late stent malapposition (LSM, that is detected during follow-up) that can be further classified into late-persistent stent malapposition (LPSM, ASM that remains at follow-up) or late-acquired stent malapposition (LASM, newly developed stent malapposition at follow-up that was not present immediately after index stent implantation). ASM has not been associated with adverse cardiac events compared with non-ASM, even in lesions with large-sized malapposition. The clinical outcomes of LSM may depend on its subtype. The recent intravascular ultrasound studies with long-term follow-up have consistently demonstrated that LASM steadily increased the risk of thrombotic events in patients with first-generation drug-eluting stents (DESs). This association has not yet been identified in LPSM. Accordingly, it is reasonable that approaches to stent malapposition should be based on its relationship with clinical outcomes. ASM may be tolerable after successful stent implantation, whereas prolonged anti-thrombotic medications and/or percutaneous interventions to modify LASM may be considered in selected patients with first-generation DESs. However, these treatments are still questionable due to lack of firm evidences.

Ticagrelor versus clopidogrel for prevention of subclinical stent thrombosis detected by optical coherence tomography in patients with drug-eluting stent implantation-a multicenter and randomized study

Introduction: This prospective, multicenter, randomized study was designed to analyze the benefits of ticagrelor over clopidogrel in reducing subclinical stent thrombosis (ST) in patients with coronary artery disease who underwent implantation of a second-generation drug-eluting stent (DES).Methods: About 352 patients with single de novo coronary stenosis were randomly assigne`d to either clopidogrel group (aspirin plus clopidogrel) or ticagrelor group (aspirin plus ticagrelor) after DES implantation for 1 year. Baseline clinical characteristics, blood chemistry markers, coronary artery angiography (CAG), and optical coherence tomography (OCT) were obtained during the index procedure. Data about clinic, CAG and OCT were also collected after 1 year follow-up. Intention-to-treat (ITT), per protocol set (PPS), and sensitivity analysis of subclinical ST were performed. Major factors associated with subclinical ST were analyzed by multivariable and univariable logistic regression models.Results: The incidence of subclinical ST in ticagrelor group was significantly low as compared to clopidogrel group (P < .05) at 1-year follow-up. Ticagrelor use was an independent factor in reducing subclinical ST (P < .05). The percentage of endothelial coverage, neointimal hyperplasia, malapposition, and edge dissection about stents were not different between the two groups (P > .05). Bleeding ratio was not markedly altered after ticagrelor treatment (P > .05). Not any significant differences were detected with regard to baseline clinical characteristics, CAG results, and DES between ticagrelor and clopidogrel groups (P > .05).Conclusion: In patients who underwent a second-generation DES implantation, using aspirin plus ticagrelor was associated with a significant reduction in subclinical ST. (ClinicalTrials.gov. Number: NCT02140801).

Relationship between neointimal strut bridge and jailed side-branch ostial area

BACKGROUND

Our study analyzed the relationship between the neointimal strut bridge and jailed side-branch (SB) ostial area in patients with coronary heart disease (CHD) who had a single drug-eluting stent (DES) crossover of the left anterior descending coronary artery (LAD)/diagonal branch (D) bifurcation.

PATIENTS AND METHODS

A total of 64 CHD patients with an LAD/D bifurcation treated by optical coherence tomography (OCT)-guided single-DES implantation and followed up at 1 year after primary percutaneous intervention (pPCI) were enrolled in our study. According to the two-dimensional OCT results, patients were divided into a non-neointimal bridge group (n = 44) and a neointimal bridge group (n = 20). Basic clinical, angiographic, 2D and 3D OCT, and DES results were analyzed.

RESULTS

The blood lipid levels of the two groups after the 1‑year follow-up were lower than the levels 1 year earlier (p < 0.05). There was a notable decrease in the SB ostial minimum lumen diameter and area directly after pPCI vs. before pPCI in both groups. The diameter stenosis directly after pPCI showed a clear increase compared with the pre-pPCI value in both groups (p < 0.05 or p < 0.01, respectively). The strut distance of the neointimal bridges in the neointimal bridge group was greater than in the non-neointimal bridge group (p < 0.05). A clearly short strut distance of the neointimal bridge was observed compared with the strut distance of the non-neointimal bridge in the neointimal bridge group (p < 0.05). A larger neointimal bridge area and a smaller SB ostial area were found in the neointimal bridge group compared with the non-neointimal bridge group (p < 0.05 or p < 0.01, respectively).

CONCLUSION

A short strut distance facilitated formation of a neointimal bridge, which significantly influenced the SB ostial area after single crossover stenting of the SB orifice at the 1‑year follow-up.