Intravascular Ultrasound to Discern Device-Specific Effects and Mechanisms of Restenosis*
Section snippets
IVUS STUDIES OF ARTERIAL REMODELING AND RESTENOSIS IN NONSTENTED LESIONS
We have performed serial IVUS studies in 336 lesions in 306 patients; 212 native coronary target lesions in 209 patients involved nonstent interventional procedures including balloon angioplasty (n = 29), directional coronary atherectomy (n = 114), high-speed rotational atherectomy (n = 45), and excimer laser angioplasty (n = 24). Adjunct balloon angioplasty was used in 138 lesions (65%) and adjunct directional coronary atherectomy (after excimer laser angioplasty or rotational atherectomy) in
IMPACT OF ENDOVASCULAR STENTS
What happens when stents are used to treat coronary artery disease? We have performed serial IVUS analysis in 115 Palmaz-Schatz stents (Johnson & Johnson Interventional Systems, Warren, NJ). The quantitative analysis differs slightly from that in nonstented lesions, since the external elastic membrane is often not visible when a stent is in place. Arterial remodeling is defined as the change in stent (rather than external elastic membrane) cross-sectional area, while tissue growth is defined as
ADJUNCT PHARMACOLOGY
Pharmacologic approaches to reduce restenosis have focused on reducing cellular proliferation. The fact that drug therapy has been unsuccessful in nonstented lesions may be attributed to selection of the wrong target,[11]since serial IVUS studies have shown that restenosis in nonstented lesions is primarily due to arterial remodeling, not cellular proliferation. On the other hand, we now have a clinically important model of restenosis that represents pure neointimal tissue proliferation—i.e.,
VALUE OF IVUS ANALYSIS
Thus, IVUS can be of value in separating late lumen loss into 2 components: arterial remodeling and tissue growth. It can also be used to detect device-specific mechanisms of restenosis—i.e., exaggerated arterial remodeling following directional coronary atherectomy and exaggerated neointimal tissue proliferation following stent implantation.
Serial IVUS can be used to study the time course of remodeling. For example, the SURE trial shows that remodeling is biphasic, with early adaptive
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This study was supported in part by the Cardiology Research Foundation and the Medlantic Research Institute, Washington, DC.