(Circulation. 1999;99:44-52.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Pathology of Acute and Chronic Coronary Stenting in Humans
From the Department of Cardiovascular Pathology (A.F., A.J.C., R.V.), Armed Forces Institute of Pathology, Washington, DC; the Mayo Clinic (G.S., W.D.E., R.S.S.), Rochester, Minn; and The University of Ottawa Heart Institute and Ottawa Civic Hospital (V.M.W.), Ottawa, Ontario, Canada.
Correspondence to Renu Virmani, MD, Department of Cardiovascular Pathology, Armed Forces Institute of Pathology, Washington, DC 20306-6000.
Background—Despite the increasing use of stents, few reports have described human coronary artery morphology early and late after stenting.
Methods and Results—Histology was performed on 55 stents in 35
coronary vessels (32 native arteries and 3 vein grafts) from 32
patients. The mean duration of stent placement was 39±82 days. Fibrin,
platelets, and neutrophils were associated with stent struts 
11
days after deployment. In stents implanted for 3 days, only 3% of
struts in contact with fibrous plaque had >20 associated inflammatory
cells compared with 44% of struts embedded in a lipid core and 36% of
struts in contact with damaged media (P<0.001).
Neointimal growth determined late
histological success, and increased
neointimal growth correlated with increased stent size
relative to the proximal reference lumen area. Neointimal
thickness was greater for struts associated with medial damage than
struts in contact with plaque (P<0.0001) or intact
media (P<0.0001). When matched for time since
treatment, neointimal cell density in stented arteries was
similar to that in unstented arteries that had undergone balloon
angioplasty and showed similar proteoglycan deposition.
Conclusions—Morphology after coronary stenting demonstrates early thrombus formation and acute inflammation followed by neointimal growth. Medial injury and lipid core penetration by struts result in increased inflammation. Neointima increases as the ratio of stent area to reference lumen area increases. Deployment strategies that reduce medial damage and avoid stent oversizing may lower the frequency of in-stent restenosis.
Key Words: stents • coronary disease • restenosis • angioplasty • pathology
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W. J. Gomes, O. Giannotti-Filho, R. P. Paez, N. A. Hossne Jr, R. Catani, and E. Buffolo Coronary artery and myocardial inflammatory reaction induced by intracoronary stent Ann. Thorac. Surg., November 1, 2003; 76(5): 1528 - 1532. [Abstract] [Full Text] [PDF]
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R.-H. Zhou, T.-S. Lee, T.-C. Tsou, F. Rannou, Y.-S. Li, S. Chien, and J. Y.-J. Shyy Stent Implantation Activates Akt in the Vessel Wall: Role of Mechanical Stretch in Vascular Smooth Muscle Cells Arterioscler Thromb Vasc Biol, November 1, 2003; 23(11): 2015 - 2020. [Abstract] [Full Text] [PDF]
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D. J. Kereiakes Adjunctive Pharmacotherapy before Percutaneous Coronary Intervention in Non-ST-Elevation Acute Coronary Syndromes: The Role of Modulating Inflammation Circulation, October 21, 2003; 108(90161): III-22 - 27. [Abstract] [Full Text] [PDF]
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A. Farb, A. P. Burke, F. D. Kolodgie, and R. Virmani Pathological Mechanisms of Fatal Late Coronary Stent Thrombosis in Humans Circulation, October 7, 2003; 108(14): 1701 - 1706. [Abstract] [Full Text] [PDF]
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L. J Wagenaar, A. J van Boven, A. C van der Wal, G. Amoroso, R. A Tio, C. M van der Loos, A. E Becker, and W. H van Gilst Differential localisation of the renin-angiotensin system in de-novo lesions and in-stent restenotic lesions in in-vivo human coronary arteries Cardiovasc Res, October 1, 2003; 59(4): 980 - 987. [Abstract] [Full Text] [PDF]
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D. J. Kereiakes, A. M. Szyniszewski, D. Wahr, H. C. Herrmann, D. I. Simon, C. Rogers, P. Kramer, W. Shear, A. C. Yeung, K. A. Shunk, et al. Phase I Drug and Light Dose-Escalation Trial of Motexafin Lutetium and Far Red Light Activation (Phototherapy) in Subjects With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention and Stent Deployment: Procedural and Long-Term Results Circulation, September 16, 2003; 108(11): 1310 - 1315. [Abstract] [Full Text] [PDF]
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B. J. Pearce and J. F. McKinsey Current Status of Intravascular Stents as Delivery Devices to Prevent Restenosis Vascular and Endovascular Surgery, July 1, 2003; 37(4): 231 - 237. [Abstract] [PDF]
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B Heublein, R Rohde, V Kaese, M Niemeyer, W Hartung, and A Haverich Biocorrosion of magnesium alloys: a new principle in cardiovascular implant technology? Heart, June 1, 2003; 89(6): 651 - 656. [Abstract] [Full Text] [PDF]
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O. Gorchakova, W. Koch, N. von Beckerath, J. Mehilli, A. Schomig, and A. Kastrati Association of a genetic variant of endothelial nitric oxide synthase with the 1 year clinical outcome after coronary stent placement Eur. Heart J., May 1, 2003; 24(9): 820 - 827. [Abstract] [Full Text] [PDF]
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M. Schillinger, M. Exner, W. Mlekusch, H. Rumpold, R. Ahmadi, S. Sabeti, W. Lang, O. Wagner, and E. Minar Acute-Phase Response after Stent Implantation in the Carotid Artery: Association with 6-month In-Stent Restenosis Radiology, May 1, 2003; 227(2): 516 - 521. [Abstract] [Full Text] [PDF]
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B E Bouma, G J Tearney, H Yabushita, M Shishkov, C R Kauffman, D DeJoseph Gauthier, B D MacNeill, S L Houser, H T Aretz, E F Halpern, et al. Evaluation of intracoronary stenting by intravascular optical coherence tomography Heart, March 1, 2003; 89(3): 317 - 320. [Abstract] [Full Text] [PDF]
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R Virmani, F D Kolodgie, A Farb, and A Lafont Drug eluting stents: are human and animal studies comparable? Heart, February 1, 2003; 89(2): 133 - 138. [Abstract] [Full Text] [PDF]
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M. R Bennett IN-STENT STENOSIS: PATHOLOGY AND IMPLICATIONS FOR THE DEVELOPMENT OF DRUG ELUTING STENTS Heart, February 1, 2003; 89(2): 218 - 224. [Full Text] [PDF]
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A. S. Kini, P. Lee, C. A. Mitre, M. E. Duffy, and S. K. Sharma Postprocedure chest pain after coronary stenting: implications on clinical restenosis J. Am. Coll. Cardiol., January 1, 2003; 41(1): 33 - 38. [Abstract] [Full Text] [PDF]
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F. J. Schoen and R. F. Padera Jr. Cardiac Surgical Pathology Card. Surg. Adult, January 1, 2003; 2(2003): 119 - 185. [Full Text]
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M. N. Babapulle and M. J. Eisenberg Coated Stents for the Prevention of Restenosis: Part I Circulation, November 19, 2002; 106(21): 2734 - 2740. [Full Text] [PDF]
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R. Virmani, F. Liistro, G. Stankovic, C. Di Mario, M. Montorfano, A. Farb, F. D. Kolodgie, and A. Colombo Mechanism of Late In-Stent Restenosis After Implantation of a Paclitaxel Derivate-Eluting Polymer Stent System in Humans Circulation, November 19, 2002; 106(21): 2649 - 2651. [Abstract] [Full Text] [PDF]
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I. P. Casserly, H. D. Aronow, P. Schoenhagen, H. Tsutsui, J. Popovich, M. Goormastic, J. J. Popma, S. E. Nissen, and E. M. Tuzcu Relationship between residual atheroma burden and neointimal growth in patients undergoing stenting: Analysis of the atherectomy before MULTI-LINK improves lumen gain and clinical outcomes trial intravascular ultrasound substudy J. Am. Coll. Cardiol., November 6, 2002; 40(9): 1573 - 1578. [Abstract] [Full Text] [PDF]
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D. P. Faxon Systemic Drug Therapy for Restenosis: "Deja Vu All Over Again" Circulation, October 29, 2002; 106(18): 2296 - 2298. [Full Text] [PDF]
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T. P. Smith Atherosclerosis and Restenosis: An Inflammatory Issue Radiology, October 1, 2002; 225(1): 10 - 12. [Full Text] [PDF]
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R. S. Schwartz, E. R. Edelman, A. Carter, N. Chronos, C. Rogers, K. A. Robinson, R. Waksman, J. Weinberger, R. L. Wilensky, D. N. Jensen, et al. Drug-Eluting Stents in Preclinical Studies: Recommended Evaluation From a Consensus Group Circulation, October 1, 2002; 106(14): 1867 - 1873. [Full Text] [PDF]
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M. Schillinger, M. Exner, W. Mlekusch, M. Haumer, R. Ahmadi, H. Rumpold, O. Wagner, and E. Minar Inflammatory Response to Stent Implantation: Differences in Femoropopliteal, Iliac, and Carotid Arteries Radiology, August 1, 2002; 224(2): 529 - 535. [Abstract] [Full Text] [PDF]
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J. E. Sousa, M. A. Costa, and A. G.M.R. Sousa What Is "The Matter" With Restenosis in 2002? Circulation, June 25, 2002; 105(25): 2932 - 2933. [Full Text] [PDF]
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A. Farb, D. K. Weber, F. D. Kolodgie, A. P. Burke, and R. Virmani Morphological Predictors of Restenosis After Coronary Stenting in Humans Circulation, June 25, 2002; 105(25): 2974 - 2980. [Abstract] [Full Text] [PDF]
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