In-stent restenosis of drug-eluting stents

Effects of TCFA on stent neointimal coverage at 9 months after EXCEL drug-eluting stent implantation assessed by OCT

BACKGROUND

The aim of this study was to investigate the effects of thin-cap fibroatheromas (TCFAs) on stent neointimal coverage at the 9‑month follow-up after EXCEL stent implantation assessed by optical coherence tomography (OCT).

METHODS

A total of 93 patients with non-ST elevation acute coronary syndrome (NSTEACS) who underwent EXCEL stent implantation were prospectively enrolled in the study and divided into a TCFA group (n = 47) and a non-TCFA group (n = 46) according to whether EXCEL stents covered the TCFAs. A TCFA was defined as a plaque with lipid content in more than one quadrant and fibrous cap thickness measuring less than 65 μm. The effect of TCFAs on stent neointimal coverage at the 9‑month follow-up after stent implantation was evaluated by OCT. The primary study endpoints were the incidence of neointimal uncoverage and stent malapposition.

RESULTS

At the 9‑month follow-up, the minimal lumen diameter of the TCFA group tended to be smaller (2.8 ± 0.8 vs. 2.1 ± 0.8, p = 0.08) and the diameter of stenosis in the TCFA group tended to be larger (15.1 ± 10.3% vs. 26.3 ± 15.1%, p = 0.08) than those in the non-TCFA group. The mean intimal thickness of the TCFA group was significantly lower than that of the non-TCFA group (67.2 ± 35.5 vs. 145.1 ± 48.7, p < 0.001). The uncovered struts (10.1 ± 9.7 vs. 4.8 ± 4.3, p = 0.05) and malapposed struts (2.1 ± 4.7 vs. 0.3 ± 0.5, p = 0.003) in the TCFA group were more significant than those in the non-TCFA group. Multivariate analysis showed that TCFAs and lesion types were independent predictors of incomplete neointimal coverage (p < 0.05), and lesion types were independent predictors of stent malapposition (p < 0.05).

CONCLUSION

In patients with NSTEACS, TCFAs delayed endothelium coverage at 9 months after stent implantation, and TCFAs were independent predictors of incomplete neointimal coverage of the stent.

lncRNA MALAT1/miR-143 axis is a potential biomarker for in-stent restenosis and is involved in the multiplication of vascular smooth muscle cells

The purpose of this study is to observe the potential value and underlying mechanism of the metastasis-associated lung adenocarcinoma transcript 1 (MALAT1)/miR-143 axis in ISR. A total of 150 participants were enrolled, including 100 patients (observation group) with coronary heart disease who underwent stent implantation in the Department of Cardiology of our hospital between January 2018 and January 2020, and 50 healthy people (control group) concurrently underwent a physical examination. Serum MALAT1 and miR-143 levels were detected by quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Tumor necrosis factor-α (TNF-α; 10 ng/mL) induced human vascular smooth muscle cells (HVSMCs). MALAT1 increased while miR-143 decreased in the observation group versus the control group (P < 0.001). The non-restenosis group had significantly elevated MALAT1 expression while decreased miR-143 expression than the restenosis group (P < 0.001). The areas under the curves of the expression of MALAT1 and miR-143 in predicting restenosis were 0.917 and 0.881, respectively. Following si-MALAT1 transfection, HVSMC multiplication and invasiveness decreased significantly (P < 0.05). miR-143-inhibitor was observed to upregulate the luciferase activity of MALAT1-WT (P < 0.05). MALAT1 is highly expressed in patients with ISR while miR-143 is decreased, and the MALAT1/miR-143 axis is a potential pathway to modulate the multiplication and invasiveness of HVSMCs.

Plasma levels of miR-143 and miR-145 are associated with coronary in-stent restenosis within 1 year of follow-up after drug-eluting stent implantation

Background

ISR remains the major adverse outcome after percutaneous coronary intervention (PCI). MicroRNAs have been demonstrated to be associated with coronary plaque and stable in the blood and can be used as biomarkers/predictors. This study aimed to investigate whether circulating microRNAs could predict in-stent restenosis (ISR).

Methods

MicroRNA array was used to detect differently expressed microRNAs between 30 ISR patients and 30 non-ISR patients in the derivation cohort. Quantitative real-time polymerase chain reaction (qRT-PCR) was used to validate the microRNA array results and to detect levels of target microRNAs in the validation cohort. All patients were followed up for at least 1 year, and major adverse cardiac events (MACEs) were recorded. Univariate and multivariate logistic regression analysis were applied to find factors associated with ISR. Receiver operating characteristics (ROC) and Kaplan-Meier survival curves were used to analyze the predictive ability of the microRNA score for ISR.

Results

MicroRNA array and qRT-PCR showed that miR-143, 145, 425, 208, and let-7g were differently expressed between ISR patients and non-ISR patients. Multivariate analysis demonstrated that lower levels of mir-143 (OR =2.36, 95% CI: 1.43–3.67) and mir-145 (OR =2.12, 95% CI: 1.56–3.48) were associated with ISR. MicroRNA scores differed statistically between ISR patients and non-ISR patients (49.18±2.05 vs. 52.10±2.41, P<0.01) and has predictive ability for ISR with an area under the curve (AUC) of 0.8206 (95% CI: 0.7155–0.9256, P<0.01). In the validation cohort, Kaplan-Meier survival curves demonstrated that patients with higher microRNA scores have better prognosis in 1 year of follow-up.

Conclusions

A lower plasma level of mir-143/145 predicts a higher risk of ISR and a worse outcome.

A case of coronary artery disease with rapid progress triggered by stent implantation

Drug-eluting stents (DESs) have a low prevalence of in-stent restenosis. However, we describe a patient with coronary artery disease with rapid progress, which might have been triggered by implantation of a DES. The patient was a 72-year-old woman who was first admitted to hospital with non-ST-segment elevated myocardial infarction and had a DES implanted after coronary angiography showed severe stenosis of the left circumflex artery. However, although she kept taking dual antiplatelet therapy, her condition deteriorated and she was admitted to hospital three more times. Angiography showed that the coronary stenosis had become more severe and was more severe not just in the stent-implanted segments, but also in other coronary arteries. Another DES and drug-eluted balloon were used. However, the stent-implanted and balloon-dilated segments became severely stenosed within 1 month. Tests for auto-immune diseases and allergies were negative. We speculate that the first DES triggered an unknown response of the coronary arteries and led to severe stenosis from the stent-implanted segment to the distal segment and other arteries.

Drug-eluting balloons versus new generation drug-eluting stents for the management of in-stent restenosis: an updated meta-analysis of randomized studies

Background

New-generation drug-eluting stents (DES) was more effective in the treatment of in-stent restenosis (ISR) compared with the first-generation DES. Drug-eluting balloons (DEB) and new-generation DES had been available strategies in treatment of bare-metal stents/DES ISR (BMS/DES-ISR). Six new randomized trials have recently examined the angiographic outcomes and one-year clinical outcomes of DEB and new generation DES in BMS/DES-ISR. However, the optimal management for BMS/DES-ISR lesions remains controversial.

Methods

We searched the randomized clinical trials evaluating the angiographic outcomes and one-year clinical outcomes of DEB and new-generation DES in patients with BMS/DES-ISR. The primary endpoints were the angiographic outcomes, including the minimal luminal diameter (MLD), diameter stenosis % (DS%), late lumen loss (LLL), and binary restenosis (BR).

Results

A total of six randomized clinical trials with 1177 BMS/DES-ISR patients were included in our meta-analysis. For angiographic outcomes, there were significantly less MLD and more DS% with DEB compared to new-generation DES (MLD: MD = -0.18, 95% CI: -0.31- -0.04, P < 0.001; DS%: MD = 5.68, 95% CI: 1.00-10.37, P < 0.001). Moreover, for one-year clinical outcomes, DEB was associated with a significant increase risk in target lesion revascularization (TLR) (RR = 2.93, 95% CI: 1.50-5.72, P = 0.002). However, DEB was associated with higher risks of major adverse cardiac event, target vessel revascularization, TLR, BR, and more DS% only in DES-ISR group.

Conclusions

DEB and new-generation DES have the similar clinical efficacy for the treatment of BMS-ISR. However, DES showed more MLD, less DS%, and a decreased risk of TLR for the treatment of DES-ISR.

Paraffin processing of stented arteries using a postfixation dissolution of metallic and polymeric stents

Studying the morphology of the arterial response to endovascular stent implantation requires embedding the explanted stented artery in rigid materials such as poly(methyl methacrylate) to enable sectioning through both the in situ stent and the arterial wall, thus maintaining the proper anatomic relationships. This is a laborious, time-consuming process. Moreover, the technical quality of stained plastic sections is typically suboptimal and, in some cases, precludes immunohistochemical analysis. Here we describe a novel technique for dissolution of metallic and plastic stents that is compatible with subsequent embedding of "destented" arteries in paraffin, fine sectioning, major staining protocols, and immunohistochemistry.

The Relationships between Polymorphisms in Genes Encoding the Growth Factors TGF-β1, PDGFB, EGF, bFGF and VEGF-A and the Restenosis Process in Patients with Stable Coronary Artery Disease Treated with Bare Metal Stent

Background

Neointima forming after stent implantation consists of vascular smooth muscle cells (VSMCs) in 90%. Growth factors TGF-β1, PDGFB, EGF, bFGF and VEGF-A play an important role in VSMC proliferation and migration to the tunica intima after arterial wall injury. The aim of this paper was an analysis of functional polymorphisms in genes encoding TGF-β1, PDGFB, EGF, bFGF and VEGF-A in relation to in-stent restenosis (ISR).

Materials and Methods

265 patients with a stable coronary artery disease (SCAD) hospitalized in our center in the years 2007–2011 were included in the study. All patients underwent stent implantation at admission to the hospital and had another coronary angiography performed due to recurrence of the ailments or a positive result of the test assessing the coronary flow reserve. Angiographically significant ISR was defined as stenosis >50% in the stented coronary artery segment. The patients were divided into two groups–with angiographically significant ISR (n = 53) and without significant ISR (n = 212). Additionally, the assessment of late lumen loss (LLL) in vessel was performed. EGF rs4444903 polymorphism was genotyped using the PCR-RFLP method whilst rs1800470 (TGFB1), rs2285094 (PDGFB) rs308395 (bFGF) and rs699947 (VEGF-A) were determined using the TaqMan method.

Results

Angiographically significant ISR was significantly less frequently observed in the group of patients with the A/A genotype of rs1800470 polymorphism (TGFB1) versus patients with A/G and G/G genotypes. In the multivariable analysis, LLL was significantly lower in patients with the A/A genotype of rs1800470 (TGFB1) versus those with the A/G and G/G genotypes and higher in patients with the A/A genotype of the VEGF-A polymorphism versus the A/C and C/C genotypes. The C/C genotype of rs2285094 (PDGFB) was associated with greater LLL compared to C/T heterozygotes and T/T homozygotes.

Conclusions

The polymorphisms rs1800470, rs2285094 and rs6999447 of the TGFB1, PDGFB and VEGF-A genes, respectively, are associated with LLL in patients with SCAD treated by PCI with a metal stent implantation.

Drug-coated balloon angioplasty for drug-eluting stent restenosis: insight from randomized controlled trials

BACKGROUND

The best treatment option for drug-eluting stent (DES) restenosis has not been established. We performed a meta-analysis to assess the clinical efficacy of drug-coated balloon (DCB) for the treatment of DES restenosis.

METHODS

Trials were identified through a literature search from January 2005 through April 2014. All randomized controlled trials were eligible for inclusion if they compared DCB with a control treatment (plain old balloon angioplasty [POBA] or DES) in patients with DES restenosis.

RESULTS

Five studies and a total of 864 patients were included in this analysis. Most end-points were significantly reduced for DCB compared with the control groups. For major adverse cardiac events, the relative risk (RR) was 0.49 (P = 0.012); for target lesion revascularization, it was 0.50 (P = 0.044); for recurrent restenosis, it was 0.41 (P = 0.002). There was a lower mortality for DCB (RR 0.29; P = 0.017). The incidence of myocardial infarction was numerically lower, but without statistical significance (RR 0.76; P = 0.55). The DCB effect was more pronounced when compared with POBA than when compared with DES.

CONCLUSIONS

This meta-analysis showed that DCB was superior to POBA and comparable to DES for treatment of DES restenosis. The findings in this meta-analysis cannot be extrapolated to DCB in general, because all DCB used in trials included was a single brand of paclitaxel-coated balloon.