(Circulation. 1999;99:44-52.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
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.
| Abstract |
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Methods and ResultsHistology 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.
ConclusionsMorphology 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
| Introduction |
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Although stents reduce restenosis rates in carefully selected lesions,2 3 in-stent restenosis remains a recognized clinical problem5 and can be expected to increase in incidence as coronary stenting becomes more frequent and is used in less ideal lesions.6 Despite the tremendous expansion of the use of coronary stents, there have been few published data on the pathology of stents deployed in human coronary arteries.7 8 9 The pathology of human coronary stenting may provide insights into the biology of stentvessel wall interaction and guide approaches to therapies to prevent or treat in-stent restenosis.
| Methods |
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3 days, inflammation around each strut was assessed, and
the following scale for inflammatory cells adjacent to struts was used:
1+, 0 to 10 inflammatory cells/strut; 2+, 11 to 20 inflammatory
cells/strut; and 3+, >20 inflammatory cells/strut. Immunohistochemical
staining for detection of smooth muscle cells and macrophages
was performed in selected cases.
In native coronary arteries stented for >30 days, intimal
thickness at each strut was measured and strut location recorded
(in contact with plaque, intact media, or damaged media). A long-term
histological success was defined as a percent area
stenosis
75% and failure as stenosis >75%. Native
coronary arteries stented for >30 days (5 stents) were
compared with coronary arteries with PTCA alone (10 arteries)
matched for duration of stent placement or PTCA. Staining with Alcian
blue was performed to identify proteoglycans in the
neointima and their component
glycosaminoglycans (hyaluronic acid, chondroitin
sulfate, dermatan sulfate, and heparan sulfate), and staining was
repeated after 3 hours of testicular hyalidase digestion.
Neointimal cell density and neointimal
thickness were determined.
| Results |
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The mean duration of stent implantation for the 55 stents was 39±82
days (range, 0.5 to 390 days), with 25 stents (from 14 patients)
examined
3 days after implantation, 8 stents (4 patients) from
4 to
11 days, 11 stents (4 patients) from
12 to
30 days, and 11 stents
(10 patients) after >30 days (mean, 175±105 days). A total of 142
arterial sections (137 native coronary arteries and
5 saphenous vein bypass grafts) containing stents were analyzed
(Table 1
).
|
Plaque compression (Figure 1
) by stent
struts was observed in 30 (94%) of 32 patients and 129 (91%) of 142
arterial sections and was seen in all stent designs. A
lipid core was present in the plaque in 66 sections (21 of 32
patients), and the core was focally penetrated by stent struts in 17
sections (26%; 11 patients; Figure 2
):
14 of 44 sections containing a Palmaz-Schatz stent, 2 of 13 containing
a Gianturco-Roubin stent, 0 of 1 containing a Wiktor stent, and 1 of 8
containing a Gianturco-Roubin II stent.
|
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Platelet-rich thrombi were associated with stent struts (Figure 3A
) in 65 of the 142 arterial
sections (19 of 32 patients) and were related to the duration of stent
implantation: 44 (72%) of 61 sections at
3 days (13 of 14 patients),
14 (78%) of 18 sections at 4 to 11 days (3 of 4 patients), 7 (24%) of
29 sections at 12 to 30 days (2 of 4 patients), and 0 of 34 sections at
>30 days (0 of 11 patients (P<0.0001). The presence of
platelet deposition around stent struts at
3 days was similar in
Palmaz-Schatz stents (33 [80%] of 41 sections) compared with
Gianturco-Roubin stents (8 [62%] of 13 sections; P=NS).
Fibrin-rich thrombi were also commonly seen around stent struts,
especially early after stenting (Figure 3B
). All 79
arterial sections from stents at
11 days (in 18 of 18
patients) had fibrin associated with stent struts; conversely, 12
(19%) of 63 sections and 7 of 14 patients at
12 days had stent
fibrin (P<0.0001).
|
Acute inflammatory cells (neutrophils) associated with stent struts
were present in 48 (79%) of 61 arterial sections and
12 of 14 patients in stents implanted for
3 days, 15 (83%) of 18 at
4 to 11 days (3 of 4 patients), 21 (72%) of 29 at 12 to 30 days (3 of
4 patients), and 0 of 34 at >30 days (P<0.0001 for all
time points versus >30 days). Chronic inflammatory cells (lymphocytes
and macrophages) around stent struts were also commonly seen at
all time points: 50 (82%) of 61 sections at
3 days (11 of 14
patients), 12 (67%) of 18 sections at 4 to 11 days (3 of 4 patients),
28 (97%) of 29 sections at 12 to 30 days (4 of 4 patients), and 29
(85%) of 34 sections at >30 days (9 of 10 patients).
Inflammation associated with stents
3 days after implant in native
coronary arteries was related to the underlying
arterial wall morphology (Figures 4
and 5
);
71% of struts in contact with fibrous plaque had
10 associated
inflammatory cells (1+ inflammation) compared with 11% of struts
embedded in a lipid core and 19% of struts in contact with damaged
media. In contrast, only 3% of struts in contact with fibrous plaque
had 3+ inflammation (>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).
|
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A neointima consisting of spindle-shaped mesenchymal cells
(
-actin positive smooth muscle cells) within a proteoglycan matrix
associated with stent struts was not present in any section in any
of the 18 patients with
11 days implant duration; 45% of sections (2
of 4 patients) at 12 to 30 days (Figure 6
) and 100% of sections (all 10
patients) at >30 days had spindle-shaped cells in a proteoglycan-rich
matrix (P<0.0001). Multinucleated giant cells were
present in only 3 (10%) of 29 sections at 12 to 30 days and were
more frequently seen in older stents (10 [29%] of 34 sections at
>30 days; Figure 7
).
|
|
The findings in the 3 patients with stenting of saphenous vein grafts
were similar to those in the 32 patients with stenting in native
arteries. In a 3-day-old Palmaz-Schatz stent, the stent wires focally
penetrated the thin fibrous cap and were embedded in the large necrotic
core of the lipid-rich plaque, with the necrotic core prolapsing into
the lumen (Figure 8
). A well-defined
neointima (smooth muscle cells in a proteoglycan-collagen
matrix), focal plaque compression, and chronic inflammatory cells
associated with stent struts were present in the 2 patients with
chronic (120 and 270 days) Palmaz-Schatz stents in vein bypass
grafts.
|
Arterial Injury and Coronary Stenting
There were a total of 1036 stent strut sites identified in the 137
sections of native coronary arteries, of which 643 (62%) of
1036 struts were in direct contact with atherosclerotic plaque. Of the
remaining 393 struts (38%) in contact with the media, medial damage
was present at 120 struts (30%) and medial compression without
laceration of the internal elastic lamina (IEL) at 215 struts (55%);
the media was unremarkable at 58 struts (15%). The mean
arterial injury score (Schwartz scale10 ) for
the arterial sections in which focal medial damage was
present was 0.73±0.80. When medial damage was absent and stent
struts were associated with a normal or compressed media, the injury
score was 0.11±0.21.
Neointimal Growth in Long-Term Stenting
In stents implanted for >30 days (mean, 175±105 days),
neointimal thickness at stent strut sites was greater when
medial damage (medial laceration or rupture) was present
(0.69±0.29 mm) than when struts were in contact with plaque
(0.33±0.26 mm; P<0.0001) or struts in contact with an
intact media (0.29±0.23 mm, P<0.0001, Figure 9
). Ultimate histological
success was dependent on lumen area and neointimal growth
within the stent (Table 2
). The mean
neointimal area and neointima area/stent area
in successes were 2.2±1.1 and 0.39±0.12
mm2, respectively, versus 3.9±1.9 and
0.68±0.15 mm2 in failures, respectively
(P<0.006 and P<0.0001). There were no
differences between successes and failures with respect to areas of the
external elastic lamina, IEL, plaque, or stent (Table 2
). There
was a significant linear correlation (P<0.0001,
R2=0.54) between increased
neointimal growth and increased stent size relative to the
proximal reference coronary artery lumen (Figure 10
).
|
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Chronic Stenting Versus PTCA: Neointimal Cellularity
and Proteoglycans
The number of neointimal
cells/mm2 in native coronary arteries
stented for >30 days was 3280±869, similar to that in PTCA arteries
(3260±851 cells/mm2; Figure 11
, A1-A2, B1-B2) matched for time
since treatment (195±131 days for stents and 180±137 days for PTCA).
The neointimal area was greater in the stented segments
than in PTCA arteries (3.1±1.6 versus 1.9±1.2
mm2, respectively; P<0.05). However,
IEL area was larger (11.6±2.1 mm2) with
stent placement than with PTCA (7.9±2.1
mm2, P=0.0001), so that the
neointima corrected for artery size
(neointima/IEL) was similar in stents and PTCA (0.26±0.16
versus 0.26±0.10, respectively; P=NS). The mean
neointimal thickness in the stented arteries
(0.39±0.26 mm) was smaller than in PTCA vessels (0.51±0.24
mm), but this difference did not reach statistical significance.
|
Alcian blue staining of stented and matched PTCA arteries
demonstrated similar patterns of neointimal proteoglycan
deposition. Alcian blue staining showed strong blue staining of the
neointima in stented and PTCA arteries (Figure 11
, A3 and B3). After testicular hyalidase digestion, there was similar
light staining for heparan and dermatan sulfate in stented and PTCA
arteries (Figure 11
, A4 and B4). These data identify
chondroitin sulfate and hyaluronic acid as the predominant
neointimal proteoglycans in PTCA and stented arteries.
| Discussion |
|---|
|
|
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11 days), fibrin,
platelets, and acute inflammatory cells were nearly always
present in association with stent struts. The
stentarterial wall interface influenced the severity of
associated inflammation; increased numbers of inflammatory cells were
seen when the stent strut was adjacent to injured media or lipid core
rather than fibrous plaque. Chronic inflammation was also commonly
observed adjacent to stent struts at all time points, especially
12
days after stenting. Plaque was compressed by stent struts (seen in
91% of vessel sections) in the present study. However, the concept
that stents provide a boundary that excludes the underlying plaque from
the lumen was not supported by the present study; penetration of
the stent struts into a lipid core was common (26% of
arterial sections with a lipid core had stent struts
embedded in the core). A neointima containing smooth muscle
cells was recognized beginning
2 weeks after stenting. In longer-term stents (>30 days after implant), histological success or failure was determined by neointimal growth within the stent and was not influenced by artery or stent size. Neointimal thickness was increased when medial damage was present compared with struts in contact with atherosclerotic plaque or an intact media. Furthermore, increased intrastent neointimal growth was present in histological failures, and increased neointimal area correlated with increased stent size relative to the proximal reference artery lumen. Therefore, stent oversizing relative to the reference lumen appears to be an undesirable goal in deployment. Intravascular ultrasound may be particularly useful in determining proximal reference lumen area. A stenting strategy in which stents are expanded to a point at which no gradient exists from the proximal reference to the stent may be beneficial. The present study is the first to compare whole arterial sections and to show neointimal cell density and type of proteoglycan deposition in coronary stents similar to those in matched PTCA coronary vessels. In these arteries, the neointimal area was greater in stented arteries than in arteries with PTCA, but this difference was accounted for by the larger vessel size in the stent group.
Previous Pathological Studies of Stenting in Humans
Few pathological observations of coronary stenting
in humans have been reported. Anderson et al8
reported pathological findings in 4 cases of Gianturco-Roubin stenting
in coronary vessels: 2 native coronary arteries and 2
coronary bypass vein grafts. At 21 days, stent
endothelialization was present, and a thin
neointima containing smooth muscle cells was
seen.8 In vein grafts at 19 weeks and 6 months, a smooth
muscle cellrich neointima and occasional chronic
inflammatory cells were seen.8 In a study of 11 human
coronary stents, 4 of which were placed for restenosis
after PTCA, Komatsu et al9 showed actin-positive intimal
smooth muscle cells 30 days after stenting. Van Beusekom et
al7 studied saphenous vein coronary bypass grafts
with Wallstents (21 stents in 10 patients). At 3 days, leukocytes,
platelets, and fibrin were evident, and at 3 months, there was
complete endothelial stent coverage and a smooth muscle
cellrich neointima. At 6 to 10 months, atherosclerotic
plaque, foam cells, and cholesterol crystals were observed;
it was suggested that stent- induced atheroma formation
may occur.7 In the present study, the
neointima was composed of smooth muscle cells in a
proteoglycan-rich matrix. The presence of atherosclerotic plaque within
the stent is likely due to penetration of struts into the necrotic core
and prolapse of plaque between stent wires rather than stent-induced
accelerated atherosclerosis.
Comparison to Stenting in Experimental Animal Models
In the porcine restenosis model, thrombus adjacent
to stent struts composed of fibrin and trapped erythrocytes with acute
inflammatory cells is seen at 24 hours.11 At 7 days, there
is organization of the thrombus associated with macrophages;
however, neutrophils are still observed.11 From 14 to 28
days after stenting, smooth muscle cells are the predominant cell type,
with occasional chronic inflammatory cells present.11
These data in the pig model regarding inflammation and thrombus
closely reflect the findings observed in human coronary
stenting early after implantation (with a relatively longer duration of
healing in humans).
The type of vascular injury in stented normal arteries in experimental animals differs considerably from that in human atherosclerotic arteries. In normal pig arteries, for example, stent oversizing to produce a proliferative neointimal lesion results in direct medial injury (compression or laceration) by stent struts. In contrast, in humans, we observed that 62% of stent struts were in direct contact with atherosclerotic plaque, not media; medial compression by stent struts or medial damage associated with struts was present at 32% of struts.
Arterial Inflammation and Injury: Clinical
Implications
Experimental studies suggest important relationships among
inflammation, vascular injury, and neointimal growth. In
stented, nonatherosclerotic, balloon-injured rabbit iliac arteries,
peak monocyte adherence was observed 3 days after stenting, with
maximal proliferation seen at 7 days.12 There was a linear
correlation (R2=0.82 to 0.92) between
monocyte adherence and neointima at 14 days.12
Furthermore, increased vascular injury correlated with increased
neointimal growth, inflammation, and thrombus
formation.13 In the porcine double-artery injury model,
neointimal thickness was smaller at strut sites adjacent to
an intact IEL and media than at areas of medial loss.14
The observations from experimental work showing correlations among
arterial injury, inflammation, and neointima
and data from the present study demonstrating increased
inflammation associated with stent struts in the vicinity of damaged
media and increased neointimal thickness at struts
associated with medial damage suggest that avoidance of severe
arterial injury during catheter-based interventions with
stents may have a beneficial effect on late neointimal
growth. Data from the present study showing the positive
association of neointimal growth and increased stent sizing
relative to the proximal reference lumen (a reflection of probable
increased arterial injury) are supportive of
stent-deployment techniques that can reduce arterial
injury. Novel devices that do not require very high balloon inflations
to accomplish close apposition of the stent to the arterial
wall (eg, self-expanding stents) are currently under clinical
trial.
Limitations
The findings in the present study are derived from descriptive
pathology. Because most of the tissues analyzed were obtained
at autopsy, the results presented may not be
representative of persons who receive stents and
survive. However, the present study is the first to report
histological findings from a large series of stents
placed in native human coronary arteries, and a majority of
segments with stents in place for >30 days demonstrated
histological success.
Conclusions
Morphology after coronary stent placement demonstrates the
following sequence of events: thrombus formation and acute inflammation
early after deployment, with subsequent neointimal growth.
Increased inflammation early after stenting is associated with medial
injury and lipid core penetration by stent struts. Medial damage and
stent oversizing relative to the reference arterial lumen
are associated with increased neointimal growth.
| Footnotes |
|---|
Received May 13, 1998; revision received September 1, 1998; accepted September 16, 1998.
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J. M. Wilson and J. T. Willerson Myocardial Revascularization with Percutaneous Devices Card. Surg. Adult, January 1, 2008; 3(2008): 573 - 598. [Full Text] |
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C. P. Vicente, L. He, and D. M. Tollefsen Accelerated atherogenesis and neointima formation in heparin cofactor II deficient mice Blood, December 15, 2007; 110(13): 4261 - 4267. [Abstract] [Full Text] [PDF] |
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K. M. Das, A. A. El-Menyar, A. M. Salam, R. Singh, W. A. K. Dabdoob, H. A. Albinali, and J. Al Suwaidi Contrast-enhanced 64-Section Coronary Multidetector CT Angiography versus Conventional Coronary Angiography for Stent Assessment Radiology, November 1, 2007; 245(2): 424 - 432. [Abstract] [Full Text] [PDF] |
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C. Bode and M. Zehender The use of antiplatelet agents following percutaneous coronary intervention: focus on late stent thrombosis Eur. Heart J. Suppl., August 1, 2007; 9(suppl_D): D10 - D19. [Abstract] [Full Text] [PDF] |
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E. Camenzind Treatment of In-Stent Restenosis -- Back to the Future? N. Engl. J. Med., November 16, 2006; 355(20): 2149 - 2151. [Full Text] [PDF] |
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M. R. Patel, T. S. E. Albert, D. E. Kandzari, E. F. Honeycutt, L. K. Shaw, M. H. Sketch Jr, M. D. Elliott, R. M. Judd, and R. J. Kim Acute Myocardial Infarction: Safety of Cardiac MR Imaging after Percutaneous Revascularization with Stents Radiology, September 1, 2006; 240(3): 674 - 680. [Abstract] [Full Text] [PDF] |
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M. Takaoka, S. Uemura, H. Kawata, K.-i. Imagawa, Y. Takeda, K. Nakatani, N. Naya, M. Horii, S. Yamano, Y. Miyamoto, et al. Inflammatory Response to Acute Myocardial Infarction Augments Neointimal Hyperplasia After Vascular Injury in a Remote Artery Arterioscler Thromb Vasc Biol, September 1, 2006; 26(9): 2083 - 2089. [Abstract] [Full Text] [PDF] |
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P. Liu, S. Patil, M. Rojas, A. M. Fong, S. S. Smyth, and D. D. Patel CX3CR1 Deficiency Confers Protection From Intimal Hyperplasia After Arterial Injury Arterioscler Thromb Vasc Biol, September 1, 2006; 26(9): 2056 - 2062. [Abstract] [Full Text] [PDF] |
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R. A. Chaer, J. A. Graham, and L. Mureebe Platelet Function and Pharmacologic Inhibition Vascular and Endovascular Surgery, August 1, 2006; 40(4): 261 - 267. [Abstract] [PDF] |
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G. T. Jones, I. P. Kay, J.W. S. Chu, G.T. Wilkins, L.V. Phillips, M. McCormick, A.M. van Rij, and M.J.A. Williams Elevated Plasma Active Matrix Metalloproteinase-9 Level Is Associated With Coronary Artery In-Stent Restenosis Arterioscler Thromb Vasc Biol, July 1, 2006; 26(7): e121 - e125. [Abstract] [Full Text] [PDF] |
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S. Tsimikas Drug-Eluting Stents and Late Adverse Clinical Outcomes: Lessons Learned, Lessons Awaited J. Am. Coll. Cardiol., May 16, 2006; 47(10): 2112 - 2115. [Full Text] [PDF] |
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D. R. Holmes Jr, P. Teirstein, L. Satler, M. Sketch, J. O'Malley, J. J. Popma, R. E. Kuntz, P. J. Fitzgerald, H. Wang, E. Caramanica, et al. Sirolimus-Eluting Stents vs Vascular Brachytherapy for In-Stent Restenosis Within Bare-Metal Stents: The SISR Randomized Trial JAMA, March 15, 2006; 295(11): 1264 - 1273. [Abstract] [Full Text] [PDF] |
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E. B. Friedrich, K. Walenta, J. Scharlau, G. Nickenig, and N. Werner CD34-/CD133+/VEGFR-2+ Endothelial Progenitor Cell Subpopulation With Potent Vasoregenerative Capacities Circ. Res., February 17, 2006; 98(3): e20 - e25. [Abstract] [Full Text] [PDF] |
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A. G. Touchard and R. S. Schwartz Preclinical Restenosis Models: Challenges and Successes Toxicol Pathol, January 1, 2006; 34(1): 11 - 18. [Abstract] [Full Text] [PDF] |
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D. Zohlnhofer, J. Hausleiter, A. Kastrati, J. Mehilli, C. Goos, H. Schuhlen, J. Pache, G. Pogatsa-Murray, U. Heemann, J. Dirschinger, et al. A Randomized, Double-Blind, Placebo-Controlled Trial on Restenosis Prevention by the Receptor Tyrosine Kinase Inhibitor Imatinib J. Am. Coll. Cardiol., December 6, 2005; 46(11): 1999 - 2003. [Abstract] [Full Text] [PDF] |
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A. C. Morton, N. D. Arnold, J. Gunn, R. Varcoe, S. E. Francis, S. K. Dower, and D. C. Crossman Interleukin-1 receptor antagonist alters the response to vessel wall injury in a porcine coronary artery model Cardiovasc Res, December 1, 2005; 68(3): 493 - 501. [Abstract] [Full Text] [PDF] |
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J. Aoki, A. C. Abizaid, P. W. Serruys, A. T.L. Ong, E. Boersma, J. E. Sousa, and N. Bruining Evaluation of Four-Year Coronary Artery Response After Sirolimus-Eluting Stent Implantation Using Serial Quantitative Intravascular Ultrasound and Computer-Assisted Grayscale Value Analysis for Plaque Composition in Event-Free Patients J. Am. Coll. Cardiol., November 1, 2005; 46(9): 1670 - 1676. [Abstract] [Full Text] [PDF] |
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J. Steffel, R. A. Latini, A. Akhmedov, D. Zimmermann, P. Zimmerling, T. F. Luscher, and F. C. Tanner Rapamycin, but Not FK-506, Increases Endothelial Tissue Factor Expression: Implications for Drug-Eluting Stent Design Circulation, September 27, 2005; 112(13): 2002 - 2011. [Abstract] [Full Text] [PDF] |
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H. Ono, T. Ichiki, H. Ohtsubo, K. Fukuyama, I. Imayama, Y. Hashiguchi, J. Sadoshima, and K. Sunagawa Critical Role of Mst1 in Vascular Remodeling After Injury Arterioscler Thromb Vasc Biol, September 1, 2005; 25(9): 1871 - 1876. [Abstract] [Full Text] [PDF] |
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Y. Kitta, T. Nakamura, Y. Kodama, H. Takano, K. Umetani, D. Fujioka, Y. Saito, K.-i. Kawabata, J.-e. Obata, Y. Ichigi, et al. Endothelial Vasomotor Dysfunction in the Brachial Artery Is Associated With Late In-Stent Coronary Restenosis J. Am. Coll. Cardiol., August 16, 2005; 46(4): 648 - 655. [Abstract] [Full Text] [PDF] |
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P. H. Grewe, K. M. Muller, M. Lindstaedt, A. Germing, A. Muller, A. Mugge, and T. Deneke Reaction Patterns of the Tracheobronchial Wall to Implanted Noncovered Metal Stents Chest, August 1, 2005; 128(2): 986 - 990. [Abstract] [Full Text] [PDF] |
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J. Pache, A. Dibra, J. Mehilli, J. Dirschinger, A. Schomig, and A. Kastrati Drug-eluting stents compared with thin-strut bare stents for the reduction of restenosis: a prospective, randomized trial Eur. Heart J., July 1, 2005; 26(13): 1262 - 1268. [Abstract] [Full Text] [PDF] |
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S. P. Lownie, D. M. Pelz, D. H. Lee, S. Men, I. Gulka, and P. Kalapos Efficacy of Treatment of Severe Carotid Bifurcation Stenosis By Using Self-Expanding Stents without Deliberate Use of Angioplasty Balloons AJNR Am. J. Neuroradiol., May 1, 2005; 26(5): 1241 - 1248. [Abstract] [Full Text] [PDF] |
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P. Agostoni, G. G.L. Biondi-Zoccai, G. L. Gasparini, M. Anselmi, G. Morando, M. Turri, A. Abbate, E. P. McFadden, C. Vassanelli, P. Zardini, et al. Is bare-metal stenting superior to balloon angioplasty for small vessel coronary artery disease? Evidence from a meta-analysis of randomized trials Eur. Heart J., May 1, 2005; 26(9): 881 - 889. [Abstract] [Full Text] [PDF] |
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J. F. LaDisa Jr., Lars. E. Olson, R. C. Molthen, D. A. Hettrick, P. F. Pratt, M. D. Hardel, J. R. Kersten, D. C. Warltier, and P. S. Pagel Alterations in wall shear stress predict sites of neointimal hyperplasia after stent implantation in rabbit iliac arteries Am J Physiol Heart Circ Physiol, May 1, 2005; 288(5): H2465 - H2475. [Abstract] [Full Text] [PDF] |
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J. I. Rotmans, P. M.T. Pattynama, H. J.M. Verhagen, I. Hino, E. Velema, G. Pasterkamp, and E. S.G. Stroes Sirolimus-Eluting Stents to Abolish Intimal Hyperplasia and Improve Flow in Porcine Arteriovenous Grafts: A 4-Week Follow-Up Study Circulation, March 29, 2005; 111(12): 1537 - 1542. [Abstract] [Full Text] [PDF] |
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A. C. Newby Dual Role of Matrix Metalloproteinases (Matrixins) in Intimal Thickening and Atherosclerotic Plaque Rupture Physiol Rev, January 1, 2005; 85(1): 1 - 31. [Abstract] [Full Text] [PDF] |
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R. S. Schwartz, N. A. Chronos, and R. Virmani Preclinical restenosis models and drug-eluting stents: Still important, still much to learn J. Am. Coll. Cardiol., October 6, 2004; 44(7): 1373 - 1385. [Abstract] [Full Text] [PDF] |
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A. Farb, F. D. Kolodgie, J.-Y. Hwang, A. P. Burke, K. Tefera, D. K. Weber, T. N. Wight, and R. Virmani Extracellular Matrix Changes in Stented Human Coronary Arteries Circulation, August 24, 2004; 110(8): 940 - 947. [Abstract] [Full Text] [PDF] |
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M. Mazighi, A. Pelle, W. Gonzalez, E. M. Mtairag, M. Philippe, D. Henin, J.-B. Michel, and L. J. Feldman IL-10 inhibits vascular smooth muscle cell activation in vitro and in vivo Am J Physiol Heart Circ Physiol, August 1, 2004; 287(2): H866 - H871. [Abstract] [Full Text] [PDF] |
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J. F. LaDisa Jr., L. E. Olson, I. Guler, D. A. Hettrick, S. H. Audi, J. R. Kersten, D. C. Warltier, and P. S. Pagel Stent design properties and deployment ratio influence indexes of wall shear stress: a three-dimensional computational fluid dynamics investigation within a normal artery J Appl Physiol, July 1, 2004; 97(1): 424 - 430. [Abstract] [Full Text] [PDF] |
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D. M. Tollefsen Does Heparin Cofactor II Modulate Atherosclerosis and Restenosis? Circulation, June 8, 2004; 109(22): 2682 - 2684. [Full Text] [PDF] |
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X. Ma and E. R. O'Brien Antagonism of the {alpha}4 integrin subunit attenuates the acute inflammatory response to stent implantation yet is insufficient to prevent late intimal formation J. Leukoc. Biol., June 1, 2004; 75(6): 1016 - 1021. [Abstract] [Full Text] [PDF] |
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M. Exner, M. Schillinger, E. Minar, W. Mlekusch, S. Sabeti, G. Endler, M. Raith, C. Mannhalter, and O. Wagner Interleukin-6 Promoter Genotype and Restenosis after Femoropopliteal Balloon Angioplasty: Initial Observations Radiology, June 1, 2004; 231(3): 839 - 844. [Abstract] [Full Text] [PDF] |
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T. M. Dewey, K. Crumrine, M. A. Herbert, A. Leonard, S. L. Prince, C. Worley, J. R. Edgerton, M. J. Magee, and M. J. Mack First-year outcomes of beating heart coronary artery bypass grafting using proximal mechanical connectors Ann. Thorac. Surg., May 1, 2004; 77(5): 1542 - 1549. [Abstract] [Full Text] [PDF] |
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P. H Chong and J. W. Cheng Early Experiences and Clinical Implications of Drug-Eluting Stents: Part 1 Ann. Pharmacother., April 1, 2004; 38(4): 661 - 669. [Abstract] [Full Text] [PDF] |
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M. Schillinger, M. Exner, E. Minar, W. Mlekusch, M. Mullner, C. Mannhalter, F. H. Bach, and O. Wagner Heme oxygenase-1 genotype and restenosis after balloon angioplasty: a novel vascular protective factor J. Am. Coll. Cardiol., March 17, 2004; 43(6): 950 - 957. [Abstract] [Full Text] [PDF] |
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H. Kamiya, T. Ushijima, K. Mukai, C. Ikeda, K. Ueyama, and G. Watanabe Late patency of the left internal thoracic artery graft in patients with and without previous successful percutaneous transluminal coronary angioplasty Interactive CardioVascular and Thoracic Surgery, March 1, 2004; 3(1): 110 - 113. [Abstract] [Full Text] [PDF] |
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P. Delafontaine, Y.-H. Song, and Y. Li Expression, Regulation, and Function of IGF-1, IGF-1R, and IGF-1 Binding Proteins in Blood Vessels Arterioscler Thromb Vasc Biol, March 1, 2004; 24(3): 435 - 444. [Abstract] [Full Text] |
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D. R. Holmes Jr, B. G. Firth, and D. L. Wood Paradigm shifts in cardiovascular medicine J. Am. Coll. Cardiol., February 18, 2004; 43(4): 507 - 512. [Abstract] [Full Text] [PDF] |
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N. Takamori, H. Azuma, M. Kato, S. Hashizume, K.-i. Aihara, M. Akaike, K. Tamura, and T. Matsumoto High Plasma Heparin Cofactor II Activity Is Associated With Reduced Incidence of In-Stent Restenosis After Percutaneous Coronary Intervention Circulation, February 3, 2004; 109(4): 481 - 486. [Abstract] [Full Text] [PDF] |
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L. L. Johnson, L. M. Schofield, D. K. Weber, F. Kolodgie, R. Virmani, and B. A. Khaw Uptake of 111In-Z2D3 on SPECT Imaging in a Swine Model of Coronary Stent Restenosis Correlated with Cell Proliferation J. Nucl. Med., February 1, 2004; 45(2): 294 - 299. [Abstract] [Full Text] [PDF] |
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M Jaster, V Fuster, P Rosenthal, M Pauschinger, Q-V Tran, D Janssen, W Hinkelbein, P Schwimmbeck, H-P Schultheiss, and U Rauch Catheter based intracoronary brachytherapy leads to increased platelet activation Heart, February 1, 2004; 90(2): 160 - 164. [Abstract] [Full Text] [PDF] |
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M. Schillinger, W. Mlekusch, R. M. Wolfram, A. C. Budinsky, M. Exner, H. Rumpold, O. Wagner, B. Pokrajac, R. Potter, and E. Minar Endovascular Brachytherapy: Effect on Acute Inflammatory Response after Percutaneous Femoropopliteal Arterial Interventions Radiology, February 1, 2004; 230(2): 556 - 560. [Abstract] [Full Text] [PDF] |
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G. W. Stone, S. G. Ellis, D. A. Cox, J. Hermiller, C. O'Shaughnessy, J. T. Mann, M. Turco, R. Caputo, P. Bergin, J. Greenberg, et al. A Polymer-Based, Paclitaxel-Eluting Stent in Patients with Coronary Artery Disease N. Engl. J. Med., January 15, 2004; 350(3): 221 - 231. [Abstract] [Full Text] [PDF] |
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A. Colombo and G. Sangiorgi The monocyte: the key in the lock to reduce stent hyperplasia? J. Am. Coll. Cardiol., January 7, 2004; 43(1): 24 - 26. [Full Text] [PDF] |
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S. Sakai, K. Mizuno, S. Yokoyama, J. Tanabe, T. Shinada, K. Seimiya, M. Takano, T. Ohba, M. Tomimura, R. Uemura, et al. Morphologic changes in infarct-related plaque after coronary stent placement: A serial angioscopy study J. Am. Coll. Cardiol., November 5, 2003; 42(9): 1558 - 1565. [Abstract] [Full Text] [PDF] |
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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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K. Egashira Molecular Mechanisms Mediating Inflammation in Vascular Disease: Special Reference to Monocyte Chemoattractant Protein-1 Hypertension, March 1, 2003; 41(3): 834 - 841. [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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