Korean Circ J.  2017 Nov;47(6):823-832. 10.4070/kcj.2017.0157.

Formation and Transformation of Neointima after Drug-eluting Stent Implantation: Insights from Optical Coherence Tomographic Studies

• Lee SY
• Hong MK
• Jang Y

• KMID: 2396474
• DOI: http://doi.org/10.4070/kcj.2017.0157

Abstract

After coronary stent implantation, neointima formation resembles the wound healing process as it involves the sequential processes of inflammation, granulation, and remodeling. Because antiproliferative drugs and polymers of drug-eluting stents (DESs) delay vascular healing compared with bare metal stents, fibrin deposition can remain long after stent implantation, or inflammation can be excessive. Delayed vascular healing can be associated with adverse clinical outcomes including DES thrombosis or restenosis, and poor endothelization of DES neointima can accelerate neoatherosclerotic change inside the neointima, further contributing to luminal restenosis or neointimal instability. Despite the lack of correlation between pathologic and optical coherence tomography (OCT) findings, OCT assessments of neointima under various circumstances can reveal vascular responses to stent therapy. Homogeneous, heterogeneous, and layered neointima patterns can be recognized by OCT and can change with time. Homogeneous neointima might be associated with better clinical outcomes after DES implantation, whereas non-homogeneous neointima or neoatherosclerotic change can be associated with poorer clinical outcomes. However, limited data are currently available, and further studies are required to comprehensively address these questions.

Keyword

Coronary artery disease; Drug-eluting stents; Optical coherence tomography

MeSH Terms

Coronary Artery Disease
Drug-Eluting Stents*
Fibrin
Inflammation
Neointima*
Phenobarbital
Polymers
Stents
Thrombosis
Tomography, Optical Coherence
Wound Healing
Fibrin
Phenobarbital
Polymers

Figure

• 

  Figure 1 Homogeneous (A), heterogeneous (B), and layered patterns (C) observed by OCT. OCT = optical coherence tomography.

• 

  Figure 2 Serial changes in neointimal patterns after DES implantation as assessed by OCT. A 58-year-old female patient treated with Nobori® DES underwent serial OCT evaluations between 9 months and 2 years after stenting. At the 9-month follow-up, heterogeneous neointima was diffusely identified through the longitudinal axis (A, B, C). At the 2-year follow-up, heterogeneous neointima was partly changed into homogeneous (D) or layered pattern (E). In contrast, heterogeneous neointima was persistent in another segment (F). DES = drug-eluting stent; OCT = optical coherence tomography.

• 

  Figure 3 Serial changes in neointima before (left panel) and after (right panel) drug-coated balloon angioplasty in in-stent restenotic lesions. (A) Homogeneous neointima: acute luminal gain was mostly derived from stent overexpansion (68.0%, 1.7 mm2/2.5 mm2). (B) Heterogeneous neointima: acute luminal gain was mostly derived from neointimal compression (85.0%, 1.7 mm2/2.0 mm2).

• 

  Figure 4 Various neoatherosclerotic neointima observed by OCT. (A) Neointima with lipid (arrow). (B) Neointima with calcification (arrow). (C) Lipidic neointima with disruption (arrow). (D) Ruptured neointima with thrombi (arrow). OCT = optical coherence tomography.

• 

  Figure 5 Development of in-stent neoatherosclerosis that caused DES restenosis. A 77-year-old male patient with exertional chest pain showed restenosis (arrow) of Cypher® DES in the left anterior descending artery (A). OCT evaluation showed lipidic neointima at the site of minimal luminal area (A). Three years prior, this patient underwent OCT evaluation that demonstrated relatively homogeneous neointima without significant luminal narrowing (B). The patient was successfully treated with Xience® DES implantation. DES = drug-eluting stent; OCT = optical coherence tomography.

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