Original Articles 27 8 1997 혈관내초음파로평가한스텐트를삽입한관동맥의 Abstract 형태학적특징 정남식 홍범기 임세중 백성일 이문형장양수 심원흠 조승연 김성순 Morphological Characteristics of Intimal Hyperplasia in Stented Coronary Arteries Assessed with Intravascular Ultrasound Namsik Chung, M.D., Bum-Kee Hong, M.D., Se-Joong Rim, M.D., Sung-Il Baik, Moon-Hyoung Lee, M.D., Yang-Soo Jang, M.D., Won-Heum Shim, M.D., Seung-Yeon Cho, M.D., Sung-Soon Kim, M.D. Cardiology Division, Yonsei Cardiovascular Center, Yonsei University, Seoul, Korea BackgroundIntravascular ultrasoundivus provides high resolution cross-sectional images of the vessels and permits the quantitative and qualitative assessment of coronary artery disease. Stent is a rigid endovascular lattice that effectively prevents elastic recoil at treated sites, but in-stent restenois is a major limitation. The purpose of the current study is to assess the contribution of neointimal hyperplasia for in-stent restenosis and the distribution and morphological characteristics of neointimal hyperplasia in deployed stents. MethodsThirty patientsmale 25 & female 531 lesions deployed with intracoronary stents underwent intravascular ultrasound imaging at follow-up at least 4 months after stenting[mean SD] 8.32.9 months. Results 1 In-stent restenosis occurred in 15 lesions out of 31 lesions at follow-up coronary angiography. There was no difference in clinical characteristics between the restenotic and the non-restenotic groups. 2 There was no difference in angiographic profiles between two groups. Deployed stents were as follows16 Palmaz-SchatzP-S stents, 12 Gianturco-RoubinG-R stents, 2 Cordis stents, and 1 Microstent II. Average diameter of stents in the restenotic and the non-restenotic groups were 3.07 0.26mm and 3.160.30mm, respectivelyp0.38. 3 There was no difference of stent cross-sectional areascsa between the non-restenotic and the restenotic groupsp0.476, but luminal CSA of the restenotic group was significantly smaller than that of the non-restenotic groupp0.006. 4 In the restenotic group, there were no differences of the maximal and the minimal diameters of 851
stents, and the mean CSAs of stents among proximal, mid, and distal segments. But the mean CSA of neointimal hyperplasia at the mid segment was larger than that at the distal segmentp0.05. There was a tendency that the mean CSA of neointimal hyperplasia at the mid segment was larger than that at the proximal segmentp0.187. These findings were the same in the non-restenotic group. 5 In the restenotic group deployed with P-S stents, there were no differences of the maximal and the minimal diameters of stents, and the mean cross-sectional areascsa of stents between each segment. But, the mean CSA of neointimal hyperplasia at the mid segment was larger than that at the distal segmentp0.05 and there was a tendency that the mean CSA of neointimal hyperplasia at the mid segment was larger than that at the proximal segmentp0.354. 6 In the morphology of neointimal hyperplasia of the restenotic group, eccentric form77%was more common than concentric form22%. Neointimal hyperplasia occurred in focal or diffuse patterns7 versus 8 cases. ConclusionsIn-stent restenosis resulted from neointimal hyperplasia which almost mainly occurred eccentrically at the mid segment of stents and in focal or diffuse patterns. Intravascular ultrasound imaging was a useful method for recognition of distribution and morphological characteristics of neointimal hyperplasia at follow-up of deployed stents. KEY WORDSIntravascular ultrasound Stent restenosis Neointimal hyperplasia. 서론 852
연구대상및방법 1. 대상환자 2. 방법 1) 관동맥조영술 2) 관동맥풍선성형술및스텐트삽입술 3) 관동맥내초음파 853
4) 관동맥내초음파영상의정량분석 Fig. 1. Schematic intravascular ultrasound view of cross sectional structures of stented coronary arteries. The outer thick & inner thin circles represent stent strutsstent cross sectional areacsa and perimeter of neointimal hyperplasia/blood interfacelumen CSA, respectively. The CSA of neointimal hyperplasia is calculated from the difference between stent CSA and lumen CSA. Fig. 2. Morphological characteristics of neointimal hyperplasia classified into concentricc and eccentrice forms. Eccentric forms are further classified into E1, E2, E3, and E4 according to the arc of neointimal hyperplasia in degree as followse1less than 90, E2more than 90 and less than 180, E3more than 180and less than 270, E4more than 270and less than 360. 5) 통계분석 결과 1. 스텐트재협착및비재협착군의임상적특성과관동맥조영소견및스텐트삽입에대한결과분석 854
Table 1. Clinical characteristics in the restenotic versus the non-restenotic group Restenosis Non-restenosis Ageyears 56.09.8 54.69.4 SexMF 141 114 Follow-up durationmonths 8.32.9 8.03.2 Type of ischemic heart diseaselesion AMI with thrombolysis 1 3 AMI without thrombolysis 3 4 Recent MI 2 Angina pectoris, stable 3 2 Angina pectoris, unstable 8 5 AMIAcute myocardial infarction Table 2. Coronary angiographic findings in the restenotic versus the non-restenotic group before stent deployment Restenosis Non-restenosis Extent of coronary artery disease 1 VD 7 7 2 VD 6 72 3 VD 2 Target lesion for stent deployment LAD 11 10 LCX 1 1 RCA 3 5 Lesion characteristics 1 A 1 4 B1 7 5 B2 5 5 C 2 2 VDVessel disease LADLeft anterior descending artery LCX Left ciricumflex artery RCA Right coronary artery 1Classified by ACC/AHA Task Force criteria Table 3. Indications of coronary stenting Restenosis Non-restenosis Bail-out 7 7 Suboptimal result 8 6 Elective 3 Table 4. Types and diameters 1 of deployed stents in the restenotic versus the non-restenotic group Restenosis Non-restenosis Stent type Palmaz-Schatz 10 6 G ianturco-roubin 5 7 Cordis 2 Micro II 1 Stent diameter 1 mm 2.5 1 3.0 11 12 3.5 3 3 4.0 1 Mean 3.070.26 3.160.30 1Diameter at nominal balloon pressure of each stent 855
2. 스텐트가삽입된관동맥의초음파소견 1) 스텐트비재협착군 2) 스텐트재협착군 Table 5. Intravascular ultrasound analysis according to stent segments in the non-restenotic group Stent Diameter of stent 1 Stent Lumen Neointimal segment Maximal Minimal CSA 2 CSA hyperplasia CSA 3 Proximal 3.00.4 2.80.3 6.21.2 5.41.6 0.81.1 Mid 3.00.4 2.90.4 6.62.0 5.31.8* 1.31.6** Distal 3.10.4 2.90.3 6.71.6 6.21.9* 0.50.9** 1Diameter of stentmm2csacross-sectional areamm 2 3Neontimal hyperplasia CSAStent CSA-Lumen CSA *p0.01 &, **p0.05,in-stent mid versus distal segment Table 6. Intravascular ultrasound analysis according to stent segments in the restenotic group Stent Diameter of stent 1 Stent Lumen Neointimal segment Maximal CSA 2 CSA 2 CSA hyperplasia CSA 3 Proximal 3.00.3 2.80.4 6.21.5 4.41.9 1.81.9 Mid 2.90.3 2.80.3 6.31.3 3.21.2* 3.11.5** Distal 2.90.4 2.80.3 6.11.1 5.21.5* 0.91.5** 1Diameter of stentmm2csacross-sectional areamm 2 3Neontimal hyperplasia CSAStent CSA-Lumen CSA *p0.01 &, **p0.05, in-stent mid versus distal segment 856
Table 7. Intravascular ultrasound analysis according to stent segments in the restenotic group deployed with Palmaz-Schatz stent Stent Diameter of stent 1 Stent Lumen Neointimal segment Maximal Minimal CSA 2 CSA hyperplasia CSA 3 Proximal 2.90.3 2.70.2 6.01.1 4.11.7 1.91.8 Mid 2.80.3 2.70.3 6.01.4 3.51.4* 2.61.5** Distal 2.90.3 2.70.3 6.01.3 5.21.4* 0.81.1** 1Diameter of stentmm 2CSACross-sectional areamm 2 3Neontimal hyperplasia CSAStent CSA-Lumen CSA *&, **p0.05, in-stent mid versus distal segment Table 8. Intravascular ultrasound analysis according to stent segments in the restenotic group deployed with Gianturco-Roubin stent Stent Diameter of stent 1 Stent Lumen Neointimal segment Maximal CSA 2 CSA 2 CSA hyperplasia CSA 3 Proximal 3.10.5 3.00.4 6.92.3 5.22.3 1.72.5 Mid 3.10.2 2.90.2 6.71.0 2.60.6 4.21.1* Distal 3.10.5 3.00.2 6.30.8 5.11.7 1.32.5* 1Diameter of stentmm 2CSACross-sectional areamm 2 3Neontimal hyperplasia CSAStent CSA-Lumen CSA *p0.05, in-stent mid versus distal segment Table 9. Morphological characteristics of neointimal hyperplasia according to stent segments in the restenotic group Stent segment C E1 E2 E3 E4 N Proximal 1 3 1 3 7 Mid 5 2 3 4 1 Distal 3 1 11 Cconcentric form of neointimal hyperplasia E eccentric form of neointimal hyperplasica classified by the arc of neointimal hyperplasia in degree as follows E1the arc of neointimal hyperplasia90 E290the arc of neointimal hyperplasia180 E3180the arc of neointimal hyperplasia270 E4270the arc of neointimal hyperplasia 360 NNo neointimal hyperplasia Table 10. Patterns of neointimal hyperplasia in the restenotic group Stent type Pattern 1 Palmaz-Schatz Gianturco-Roubin Total Focal 4 3 7 Diffuse 6 2 8 1 Number of in-stent segments involved with neointimal hyperplasiaonefocal patterntwo diffuse pattern 3) 스텐트내신생내막증식의형태학적특징 857
고안 858
연구의제한점 요약 연구배경 : 방법 : 결과 : 859
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