oct assessment of late stent malapposition after des department of cardiology the 2 nd affiliated...
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OCT Assessment of Late Stent Malapposition after DES
Department of CardiologyThe 2nd affiliated hospital of
HMUJingbo Hou
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Certain distance between vascular wall and at least one stent strut.
支架贴壁不良是指至少一个以上支架小梁与血管壁之间存在一定的空隙(距离);
SM include instant stent malapposition late stent malapposition : continuous malapposition after
stent implantation. Acquired stent malapposition.
Late stent malapposition -- What is it?
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3
Acquired LSM
Baseline
Positive remodeling
No remodeling
Follow-up
* Study by Dr. Abizaid, presented at TCT 2005.
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Mechanism for LSM
Vascular wall positive
remodelling
Absorption of
thrombus or plaque
component (in ACS)
Chronic retraction of
stent
Unclear for exact
pathologic mechanism
Delayed healing
Chronic inflammation
Hypersensitive
reaction
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Stent strut neointimal coverage
J Am Coll Cardiol Img, 2010; 3:76-84
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Malapposition
Which is better?
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Long-term follow-up of LSM
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BMSn=61
SESN=80
Post-procedure ISA 9 (14.8%) 13 (16.3%)
Resolved ISA 3 (4.9%) 7 (8.7%)
Persistent ISA 6 (9.8%) 6 (7.5%)
Late-acquired ISA 0 7 (8.7%)
ISA at follow-up 6 (9.8%) 13 (16.3%)
Ako J, et al. JACC. 2005; 46(6):1002-1005.
Tanabe K, et al. Circulation. 2005; 111(7):900-905.
Frequency of ISA ---in BMS and DES Trial
BMSn=240
TAXUSN=229
19 (7.9%) 16 (7.0%)
11 (4.6%) 11 (4.8%)
8 (3.3%) 5 (2.2%)
13 (5.4%) 20 (8.7%)
21 (8.8%) 25 (10.9%)
SIRIUS IVUS TAXUS II IVUS
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OCT assessment of LSM
• Late stent malapposition is defined when the distance between its inner surface reflection and the vessel wall is more than strut thickness plus polymer thickness plus OCT resolution.
Stent type Metal strut
thickness(μm)
Polymer
thickness(μm)
Malapposition
(μm)
Cypher Select 140 7 ≥160
Taxus Liberte 97 15 ≥130
Firebird Ⅰ 100 10 ≥125
Partner 114 6 ≥130
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OCT assessment of LSM
Measurement of MSA and MSD. Double-headed red arrow is MSD. Dotted area is MSA.
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LSM in our center
• LSM in 126 DES stents in 68 patients at
least 1 year after implantation were
evaluated by OCT in our department ;
• MSD, MSA, RLA and RSA were examined
by OCT.
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Clinical dataPatient number 68
Stent number 126
Age(years) 60.1±10.2
Male gender, n (%) 57(83.8)
Hypertension, n (%) 40(58.8)
Hyperlipidemia, n (%) 23(33.8)
Diabetes Mellitus, n (%) 21(30.9)
Smoking 31(45.6)
Target vessels, n (%)
LAD 65(51.6)
LCX 22(17.4)
RCA 39(31.0)
Stent type, n (%)
Cypher select, n (%) 26(20.6)
Taxus Liberte, n (%) 15(11.9)
Partner, n (%) 51(40.5)
Firebird Ⅰ , n (%) 34(27.0)
Average stent diameter (mm) 3.1±0.5
Average stent length (mm) 25.1±6.8
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Quantitative analysis
Patient vessel RSA
(mm2)
RLA
(mm2)
MSA
(mm2)
MSD
(μm)
MSA
/RSA(%)
DES time
(years)
1 LAD 7.2 6.4 5.6 1050 77.8 1.1
2 RCA 7.1 7.0 1.2 310 16.9 1.5
3 LAD 13.1 12.1 1.7 460 13.0 1.9
4 LAD 6.5 4.7 0.9 520 13.9 1.5
5 LAD 5.7 4.7 1.2 800 21.1 1.3
6 LAD 10.3 10.8 1.8 320 17.5 1.3
7 LAD 5.5 5.1 1.3 650 23.6 1.2
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14
Late stent thrombosis—DES: Factors to consider
Discontinuation of antiplatelet therapy
Delayedendothelialization
Late incompleteapposition
Polymer hypersensitivity/inflammation
Late stentthrombosisLate stentthrombosis
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Clinical information
• Male , 43-year-old ; • 2008-4-18:
Selective PCI for subacute anterior MI ,2 DES stents were implanted along
LAD ;• Long smoking and drinking history.
• No hypertension and diabetic history.
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Clinical information
• 2009-7-30 : After stopping using of clopidogrel
for 2 months, the patient had acute
anterior MI again. Thrombolytic
therapy was given to him in local
hospital.
• 2009-8-12 : CAG.
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2008-4-18
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2008-4-18
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2009-8-18 2008-4-18
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2008-4-18
2009-8-18
2009-8-18
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Possible reason for late thrombus and recurrent MI
• Comparison of CAG of two times of PCI, we found
obvious coronary positive remodel.
• The change of vascular wall induce late stent
malapposition.
• Late stent malapposition and stop using of dual
antiplatelet therapy were probable reasons for very late
stent thrombosis.
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What can we get from this case?
How to prevent late stent malapposition ?☺Choose suitable type of stent in ACS (BMS
or others).
☺New type stents without polymer or
biodegradable polymer to induce
reendothelization.
☺Drug therapy to prevent vascular wall
positve remodelling??
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Treatment to LSM……
☺ Prolonged dual antiplatelet treatment.
How long??
☺ Implantation for another stent.
BMS or covered stent?
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