Canadian Journal of Cardiology 30 (2014) 1462.e15e1462.e16 www.onlinecjc.ca
Images in Cardiology
Early Saphenous Vein Graft In-Stent Neoatherosclerosis by Optical Coherence Tomography Luiz F. Ybarra, MD,a Giora Weisz, MD,b Fabiana H. Rached, MD, PhD,a Marco A. Perin, MD, PhD,a and Adriano Caixeta, MD, PhDa a
Department of Cardiovascular Interventions, Hospital Israelita Albert Einstein, São Paulo, Brazil b
Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
In-stent lipid-rich neoatherosclerosis has been recently described as a mechanism of late stent failure in native coronary arteries. Previous studies have shown that this condition occurs more commonly and much earlier after drug-eluting stent than bare-metal stent implantation.1-3 This process is related to insudation of lipids superficial to the stent strut level in the early phase after percutaneous coronary intervention. Subsequently, the final transformation to lipid-laden neointima and neoatherosclerosis progress during the extended follow-up period. Enhanced neoatherosclerosis in drug-eluting stents may be explained by delayed arterial healing and endothelial cell dysfunction, which are natural barriers inhibiting lipid infiltration and migration of inflammatory cells.1 By optical coherence tomography (OCT), early in-stent restenosis (< 6 months) shows classic homogeneous highsignal imaging findings compatible with neointimal proliferation. Conversely, very late in-stent restenosis (> 5 years) presents several different image patterns, including heterogeneous tissue with a low-intensity area of lipid pools and calcification, suggesting a prominent role of atherosclerosis progression as a pathogenic mechanism.2,3 However, the
Received for publication April 5, 2014. Accepted June 11, 2014. Corresponding author: Dr Adriano Caixeta, Department of Cardiovascular Interventions, Hospital Israelita Albert Einstein, Ave Albert Einstein, 627, Morumbi, São Paulo 05652-000, Brazil. Tel./fax: þ55-11-2151-0434. E-mail: [email protected] See page 1462.e15 for disclosure information.
development of neoatherosclerosis has not yet been described in saphenous vein grafts. A 58-year-old man with a history of a 4.0 mm 38 mm everolimus-eluting stent (PROMUS Element; Boston Scientific, Natick, MA) deployed 3 years ago in a saphenous vein graft that was implanted 17 years earlier during coronary artery bypass graft surgery. The patient presented with noneST-segment-elevation acute myocardial infarction, and angiography suggested in-stent restenosis. OCT demonstrated the presence of in-stent neoatherosclerosis with lipid-laden plaque, calcification, cluster of macrophages, and a disrupted thin-cap fibroatheroma, similar to the morphologic appearance seen with typical native neoatherosclerosis (Fig. 1). Disclosures The authors have no conflicts of interest to disclose. References 1. Nakazawa G, Otsuka F, Nakano M, et al. The pathology of neoatherosclerosis in human coronary implants bare-metal and drug-eluting stents. J Am Coll Cardiol 2011;57:1314-22. 2. Yonetsu T, Kato K, Kim SJ, et al. Predictors for neoatherosclerosis: a retrospective observational study from the optical coherence tomography registry. Circ Cardiovasc Imaging 2012;5:660-6. 3. Lee SY, Shin DH, Mintz GS, et al. Optical coherence tomography-based evaluation of in-stent neoatherosclerosis in lesions with more than 50% neointimal cross-sectional area stenosis. EuroIntervention 2013;9:945-51.
http://dx.doi.org/10.1016/j.cjca.2014.06.004 0828-282X/Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
Ybarra et al. OCT Imaging of SVG Neoatherosclerosis
1462.e16
Figure 1. Angiography showing the saphenous vein graft with characteristic in-stent restenosis (middle). Optical coherence tomography (OCT) images from proximal (A) to distal (E). A thin-cap fibroatheroma has developed inside the stent. Arrowheads indicate examples of stent struts. Asterisks indicate necrotic core lipid-rich areas. Necrotic core is seen as a signal-poor region within a plaque, with poorly delineated borders, a fast signal drop off, and low OCT backscattering covered by a fibrous cap (A-E). (A) Saphenous vein graft necrotic core behind a disrupted thin fibrous cap can be seen in all 4 quadrants circumferentially. (B) Magnified image, showing mixed plaque with fibrous cap (high signal), focal calcific deposit comprising regions with sharply delineated borders, and adjacent signal-poor areas suggestive of lipid (asterisk). Note the presence of an intact fibrous cap with high signal with shadowing suggesting a cluster of macrophages (C, greyscale, arrows). Scale bars represent 500 mm. Dagger represents guide wire artifacts.
Images in Cardiology
Early Saphenous Vein Graft In-Stent Neoatherosclerosis by Optical Coherence Tomography Luiz F. Ybarra, MD,a Giora Weisz, MD,b Fabiana H. Rached, MD, PhD,a Marco A. Perin, MD, PhD,a and Adriano Caixeta, MD, PhDa a
Department of Cardiovascular Interventions, Hospital Israelita Albert Einstein, São Paulo, Brazil b
Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
In-stent lipid-rich neoatherosclerosis has been recently described as a mechanism of late stent failure in native coronary arteries. Previous studies have shown that this condition occurs more commonly and much earlier after drug-eluting stent than bare-metal stent implantation.1-3 This process is related to insudation of lipids superficial to the stent strut level in the early phase after percutaneous coronary intervention. Subsequently, the final transformation to lipid-laden neointima and neoatherosclerosis progress during the extended follow-up period. Enhanced neoatherosclerosis in drug-eluting stents may be explained by delayed arterial healing and endothelial cell dysfunction, which are natural barriers inhibiting lipid infiltration and migration of inflammatory cells.1 By optical coherence tomography (OCT), early in-stent restenosis (< 6 months) shows classic homogeneous highsignal imaging findings compatible with neointimal proliferation. Conversely, very late in-stent restenosis (> 5 years) presents several different image patterns, including heterogeneous tissue with a low-intensity area of lipid pools and calcification, suggesting a prominent role of atherosclerosis progression as a pathogenic mechanism.2,3 However, the
Received for publication April 5, 2014. Accepted June 11, 2014. Corresponding author: Dr Adriano Caixeta, Department of Cardiovascular Interventions, Hospital Israelita Albert Einstein, Ave Albert Einstein, 627, Morumbi, São Paulo 05652-000, Brazil. Tel./fax: þ55-11-2151-0434. E-mail: [email protected] See page 1462.e15 for disclosure information.
development of neoatherosclerosis has not yet been described in saphenous vein grafts. A 58-year-old man with a history of a 4.0 mm 38 mm everolimus-eluting stent (PROMUS Element; Boston Scientific, Natick, MA) deployed 3 years ago in a saphenous vein graft that was implanted 17 years earlier during coronary artery bypass graft surgery. The patient presented with noneST-segment-elevation acute myocardial infarction, and angiography suggested in-stent restenosis. OCT demonstrated the presence of in-stent neoatherosclerosis with lipid-laden plaque, calcification, cluster of macrophages, and a disrupted thin-cap fibroatheroma, similar to the morphologic appearance seen with typical native neoatherosclerosis (Fig. 1). Disclosures The authors have no conflicts of interest to disclose. References 1. Nakazawa G, Otsuka F, Nakano M, et al. The pathology of neoatherosclerosis in human coronary implants bare-metal and drug-eluting stents. J Am Coll Cardiol 2011;57:1314-22. 2. Yonetsu T, Kato K, Kim SJ, et al. Predictors for neoatherosclerosis: a retrospective observational study from the optical coherence tomography registry. Circ Cardiovasc Imaging 2012;5:660-6. 3. Lee SY, Shin DH, Mintz GS, et al. Optical coherence tomography-based evaluation of in-stent neoatherosclerosis in lesions with more than 50% neointimal cross-sectional area stenosis. EuroIntervention 2013;9:945-51.
http://dx.doi.org/10.1016/j.cjca.2014.06.004 0828-282X/Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
Ybarra et al. OCT Imaging of SVG Neoatherosclerosis
1462.e16
Figure 1. Angiography showing the saphenous vein graft with characteristic in-stent restenosis (middle). Optical coherence tomography (OCT) images from proximal (A) to distal (E). A thin-cap fibroatheroma has developed inside the stent. Arrowheads indicate examples of stent struts. Asterisks indicate necrotic core lipid-rich areas. Necrotic core is seen as a signal-poor region within a plaque, with poorly delineated borders, a fast signal drop off, and low OCT backscattering covered by a fibrous cap (A-E). (A) Saphenous vein graft necrotic core behind a disrupted thin fibrous cap can be seen in all 4 quadrants circumferentially. (B) Magnified image, showing mixed plaque with fibrous cap (high signal), focal calcific deposit comprising regions with sharply delineated borders, and adjacent signal-poor areas suggestive of lipid (asterisk). Note the presence of an intact fibrous cap with high signal with shadowing suggesting a cluster of macrophages (C, greyscale, arrows). Scale bars represent 500 mm. Dagger represents guide wire artifacts.
