Intravascular Imaging for Guiding In-Stent Restenosis and Stent Thrombosis Therapy

Emrah Erdogan, Retesh Bajaj, Alexandra Lansky, Anthony Mathur, Andreas Baumbach, Christos V Bourantas, Emrah Erdogan, Retesh Bajaj, Alexandra Lansky, Anthony Mathur, Andreas Baumbach, Christos V Bourantas

Abstract

Advances in stent technology and the design of endovascular devices with thinner struts, anti-inflammatory and antithrombotic polymers, and better drug kinetics have enhanced the safety and efficacy of the second-generation drug-eluting stents and broadened their use in the therapy of high-risk patients and complex anatomies. However, despite these developments, in-stent restenosis and stent thrombosis remain the Achilles' heel of percutaneous coronary intervention, with their cumulative incidence reaching up to 10% at 5 years following percutaneous coronary intervention. The treatment of stent failure poses challenges and is associated with a worse prognosis than conventional percutaneous coronary intervention. Several studies have recently highlighted the value of intravascular imaging in identifying causes of stent failure, underscored its role in treatment planning, and registries have shown that its use may be associated with better clinical outcomes. The present review aims to summarize the evidence in the field; it discusses the value of intravascular imaging in identifying the mechanisms of in-stent restenosis and stent thrombosis in assessing the morphological characteristics of neointima tissue that appears to determine long-term outcomes in evaluating procedural results, and presents the findings of studies supporting its value in guiding therapy in stent failure.

Keywords: intravascular ultrasound; in‐stent restenosis; optical coherence tomography.

Figures

Figure 1. Common causes of in‐stent restenosis.
Figure 1. Common causes of in‐stent restenosis.
A, Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) cross‐sections of stent underexpansion. B, Significant plaque at the stent edge is seen on IVUS and OCT. C, Thrombus extends into the lumen on IVUS and OCT. D, Nonoverlapping stents. There are no stent struts on the middle cross‐section of OCT. E, A dissection flap extends into the lumen on OCT. F, Fractured stent struts are seen.
Figure 2. Common causes of stent thrombosis.
Figure 2. Common causes of stent thrombosis.
A, Optical coherence tomography (OCT) cross‐section of stent underexpansion. B, Malapposed stent struts are seen with a significant distance from the vessel wall on OCT and intravascular ultrasound (IVUS). C, Significant plaque at the stent edge is seen on IVUS and OCT. D, A dissection flap extends into the lumen on OCT. E, Evagination and vessel wall bulging pushing the stent struts into the lumen is seen on OCT. F, Lipid‐rich neoatherosclerotic plaque appears on OCT.
Figure 3. Incidence of the most common…
Figure 3. Incidence of the most common causes of stent thrombosis according to the time of the event; a combined analysis of the PESTO (Morphological Parameters Explaining Stent Thrombosis Assessed by OCT), PRESTIGE (Prevention of Late Stent Thrombosis by an Interdisciplinary Global European Effort), and Bern registry studies.
AST indicates acute stent thrombosis; LST, late stent thrombosis; SAST, subacute stent thrombosis; and VLST, very late stent thrombosis.
Figure 4. In‐stent restenosis (ISR) treatment strategies…
Figure 4. In‐stent restenosis (ISR) treatment strategies according to the underlying mechanism and neointima characteristics assessed by intravascular imaging.
*Indicates use of DES only if there is optimal lesion preparation and expected optimal stent expansion. Ca indicates calcific; DCB, drug‐coated balloon; DES, drug‐eluting stent; ELCA, excimer laser coronary atherectomy; IVBT, intravascular brachytherapy; IVL, intravascular lithotripsy; IVUS, intravascular ultrasound; OCT optical coherence tomography; and RA, rotational atherectomy.
Figure 5. Stent thrombosis (ST) treatment strategies…
Figure 5. Stent thrombosis (ST) treatment strategies according to the underlying mechanism and neointima characteristics assessed by intravascular imaging.
*Indicates use of DES only if there is optimal lesion preparation and is expected optimal stent expansion. DES indicates drug‐eluting stent; ELCA, excimer laser coronary atherectomy; IVL, intravascular lithotripsy; IVUS, intravascular ultrasound; OCT optical coherence tomography; POBA, plain old balloon angioplasty; and RA, rotational atherectomy.
Figure 6. Advantages and limitations of intravascular…
Figure 6. Advantages and limitations of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) in assessing neointima features and detecting causes of stent failure.
indicates excellent ability of the modality to detect the specific feature; , moderate ability of the modality to detect the specific feature; , weak ability of the modality to detect the specific feature; and , the modality is unable to detect the specific feature.

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