Influence of stent design and deployment technique on neointima formation and vascular remodeling

Verschiedene Stenttypen werden in der Behandlung koronarer Stenosen verwendet. Die In-stent-restenose stellt die Hauptlimitation der Stentimplantation dar. Der intrakoronare Ultraschall (ICUS) liefert präzise Messungen über die koronare Gefäßwand sowie das Ausmaß der intimalen Hyperplasie. Die Gefäßverletzung während der Stentimplantation spielt eine entscheidende Rolle bei der Entstehung der Intimahyperplasie. Sie ist charakterisiert durch das Ausmaß der endothelialen Verletzung, insbesondere in den Wandschichten der Intima und der Media. Die stentinduzierte Gefäßverletzung ist abhängig vom Stenttyp und der Größe der Stentstreben mit entsprechender tiefer Gefäßwandverletzung. In seriellen ICUS Analysen korrelierte der Stenttyp mit der Höhe der Intimahyperplasie. Die Rolle des adaptiven Gefäßremodelling wird kontrovers diskutiert. Bei post-prozeduraler Stentexpansion wurde in sonographischen Untersuchungen ein adaptives adventitielles Remodeling beobachtet. Das Stentdesign und die Stentimplantationsstrategie bestimmen das Ausmaß der peri- und postprozeduralen koronaren Gefäßverletzung. Postprozedurale Änderungen der koronaren Morphologie sowie der Stentgeometrie sind abhängig vom Stenttyp. In der Entwicklung zukünftiger Stenttypen sollte die Reduzierung der stentinduzierten Gefäßwandverletzung eine entscheidende Rolle spielen. A variety of different stent types is available for the treatment of coronary stenosis. However, in-stent restenosis remains the major limitation for the use of these devices. Intracoronary ultrasound (ICUS) in addition to coronary angiography provides precise measurements of coronary wall dimensions during stent implantation and of intimal hyperplasia during follow-up. The extent of coronary injury during stent implantation was shown to play an important role in neointima formation. It is characterized by endothelial exposure, intima laceration, and media permeation. Stent-induced coronary injury has been considered to depend on stent design and stent strut size with consecutive deep wall laceration. ICUS analysis showed a correlation between the stent design and the amount of neointimal tissue proliferation. The role of adventitial remodeling in the process of restenosis is discussed controversially. Post-procedural stent expansion may provoke adventitial remodeling. The stent design and stenting strategy determines the extent of peri- and post- procedural coronary injury. Post-procedural coronary morphologic changes and changes of the stent geometry depend upon the stent design. Beside further modifications as the use of drug-eluting stents the decrease of stent-related vessel injury should be an important criterion for the development of future stent design.

[1]  E. Camenzind,et al.  Mechanisms of Neointima Formation and Remodeling in the Porcine Coronary Artery , 2001, Circulation.

[2]  E. Edelman,et al.  Balloon-artery interactions during stent placement: a finite element analysis approach to pressure, compliance, and stent design as contributors to vascular injury. , 1999, Circulation research.

[3]  P Hall,et al.  Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. , 1995, Circulation.

[4]  I. Penn,et al.  Intravascular ultrasound-guided optimized stent deployment. Immediate and 6 months clinical and angiographic results from the Multicenter Ultrasound Stenting in Coronaries Study (MUSIC Study) , 1998, European heart journal.

[5]  C M Gibson,et al.  Generalized model of restenosis after conventional balloon angioplasty, stenting and directional atherectomy. , 1993, Journal of the American College of Cardiology.

[6]  E. Edelman,et al.  Endovascular stent design dictates experimental restenosis and thrombosis. , 1995, Circulation.

[7]  A. Becker,et al.  Neointimal tissue response at sites of coronary stenting in humans: macroscopic, histological, and immunohistochemical analyses. , 1998, Circulation.

[8]  G. Ertl,et al.  Optimierte Expansion des Multi-Link-Stents. Eine In-vitro-Untersuchung mittels hochauflösender Röntgentechnik , 1998, Zeitschrift für Kardiologie.

[9]  A. Kastrati,et al.  Intracoronary stenting and angiographic results: strut thickness effect on restenosis outcome (ISAR-STEREO-2) trial. , 2003, Journal of the American College of Cardiology.

[10]  J. Wilcox,et al.  Identification of a potential role for the adventitia in vascular lesion formation after balloon overstretch injury of porcine coronary arteries. , 1996, Circulation.

[11]  P. D. de Feyter,et al.  Coronary wallstents show significant late, postprocedural expansion despite implantation with adjunct high-pressure balloon inflations. , 1998, The American journal of cardiology.

[12]  R E Vlietstra,et al.  Restenosis and the proportional neointimal response to coronary artery injury: results in a porcine model. , 1992, Journal of the American College of Cardiology.

[13]  G. Mintz,et al.  The impact of high pressure vs low pressure stent implantation on intimal hyperplasia and follow-up lumen dimensions; results of a randomized trial. , 2001, European heart journal.

[14]  P. Fitzgerald,et al.  Impact of Peri-Stent Remodeling on Restenosis: A Volumetric Intravascular Ultrasound Study , 2001, Circulation.

[15]  A. Zalewski,et al.  Adventitial myofibroblasts contribute to neointimal formation in injured porcine coronary arteries. , 1996, Circulation.

[16]  C. Patterson,et al.  Cell cycle in vasculoproliferative diseases: potential interventions and routes of delivery. , 2001, Circulation.

[17]  E. Edelman,et al.  Pathobiologic responses to stenting. , 1998, The American journal of cardiology.

[18]  E. Regar,et al.  Serial follow-up after optimized ultrasound-guided deployment of Palmaz-Schatz stents. In-stent neointimal proliferation without significant reference segment response. , 1997, Circulation.

[19]  M. Leon,et al.  Patterns and mechanisms of in-stent restenosis. A serial intravascular ultrasound study. , 1996, Circulation.

[20]  Larry S. Dean,et al.  Randomized Comparison of GR-II Stent and Palmaz-Schatz Stent for Elective Treatment of Coronary Stenoses , 2000, Circulation.

[21]  R. Virmani,et al.  Pathology of acute and chronic coronary stenting in humans. , 1999, Circulation.

[22]  W Rutsch,et al.  A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. Benestent Study Group. , 1994, The New England journal of medicine.

[23]  E. Regar,et al.  Serial intravascular ultrasound and quantitative coronary angiography after self-expandable wallstent coronary artery implantation. , 2000, The American journal of cardiology.

[24]  C. Jansen,et al.  Stent design related neointimal tissue proliferation in human coronary arteries; an intravascular ultrasound study. , 2001, European heart journal.

[25]  Ormiston,et al.  Clinical and Angiographic Results with the Multi-Link Stent Implanted under Intravascular Ultrasound Guidance (West-2 Study). , 1998, The Journal of invasive cardiology.

[26]  E. Regar,et al.  Ultrasound Guidance of Palmaz‐Schatz Intracoronary Stenting With a Combined Intravascular Ultrasound Balloon Catheter , 1994, Circulation.

[27]  A. Kastrati,et al.  Intracoronary Stenting and Angiographic Results: Strut Thickness Effect on Restenosis Outcome (ISAR-STEREO) Trial , 2001, Circulation.

[28]  D. Baim,et al.  Novel approach to the analysis of restenosis after the use of three new coronary devices. , 1992, Journal of the American College of Cardiology.