The role of intravascular ultrasound to guide drug-eluting stents implantation

The utility of stent enhancement to guide percutaneous coronary intervention for bifurcation lesions

AIMS

Percutaneous coronary intervention (PCI) of bifurcation lesions is complex and is technically very demanding. Coronary angiography is considered the gold standard method to guide PCI but has several limitations. The purpose of this study was to determine the utility of stent enhancement with StentBoost® (StB), a novel fluoroscopic imaging technique, and its potential role during bifurcation PCI.

METHODS AND RESULTS

This prospective study included 97 patients who underwent bifurcation PCI (98 bifurcations), using StB. Bifurcation lesions were classified according to the modified Medina classification. StB was performed in all patients to obtain improved stent visualisation and to detect optimal release and deployment. Therefore, three groups were formed, according to the quality of image: optimal visualisation, suboptimal visualisation and poor visualisation. Most of the bifurcation disease involved the main vessel (99%) and in 80 patients (81.6%) there was side branch involvement. Most bifurcations had both main vessel and side branch lesions (Medina 1,1,1) (70 patients, 71.4%). StB image quality was good in 79.6% of the cases (optimal visualisation of the stent and guidewire), was suboptimal in 19.4%, and poor in 1% (overlapping of structures or devices). In three cases, StB enabled the identification of the guidewire and angioplasty balloon passing outside stent borders during rewiring of the side branch.

CONCLUSIONS

Imaging techniques have a primary role during bifurcation PCI. StentBoost is a simple and quick method that offers several advantages, enabling improved stent visualisation, appropriate rewiring of the side branch, adequate stent expansion and optimal apposition of the struts to the wall.

Intimal hyperplasia and vascular remodeling after everolimus-eluting and sirolimus-eluting stent implantation in diabetic patients: the randomized Diabetes and Drug-Eluting Stent (DiabeDES) IV Intravascular Ultrasound trial

OBJECTIVE

To evaluate the effects of the everolimus-eluting Xience™/Promus™ stent (EES) and the sirolimus-eluting Cypher™ stent (SES) on intimal hyperplasia (IH) in diabetic patients.

BACKGROUND

Patients with diabetes mellitus have increased risk of in-stent restenosis after coronary stent implantation due to intimal hyperplasia (IH).

METHODS

In a sub study of the Randomized Comparison of Everolimus-Eluting and Sirolimus-Eluting Stents in Patients Treated with Percutaneous Coronary Intervention (SORT OUT IV trial), serial intravascular ultrasound (IVUS) 10-month follow-up data were available in 88 patients, including 48 EES and 40 SES treated patients. IVUS endpoints included IH volume, in-stent % volume obstruction and changes in external elastic membrane (EEM) volume.

RESULTS

Compared with the SES group, IH volume was increased in the EES group [median (interquartile range): 2.8 mm(3) (0.0-12.6) vs. 0.0 mm(3) (0.0-1.1), P = 0.001]. In-stent % volume obstruction was increased in EES compared to SES [median (interquartile range): 1.6% (0.0-8.2) vs. 0.0% (0.0-1.0), P = 0.001]. Peri-stent external elastic membrane (EEM) volume: (post procedure vs. follow-up EES [300 mm(3) (219-491) vs. 307 mm(3) (223-482), P = 0.73] and SES [316 mm(3) (235-399) vs. 323 mm(3) (246-404), P = 0.05]) and peri-stent plaque volume: EES [163 mm(3) (103-273) vs. 184 mm(3) (115-291), P = 0.18] and SES [186 mm(3) (139-248) vs. 175 mm(3) (153-243), P = 0.26]) were unchanged in both groups. In the proximal reference segment a significant increase in plaque area was seen in the EES group only, without vascular remodeling.

CONCLUSION

In diabetic patients, EES stent implantation was associated with increased IH volume obstruction without involvement of vascular remodeling.