Circulation, Vol 86, 1827-1835, Copyright © 1992 by American Heart Association
RE Kuntz, RD Safian, JP Carrozza, RF Fishman, M Mansour and DS Baim
BACKGROUND. We evaluated native coronary arteries treated by directional
coronary atherectomy or balloon-expandable stent placement in an effort to
derive a quantitative geometric model relating the luminal diameter
immediately after intervention to that present 6 months later. The minimal
luminal diameter of each lesion was measured before and immediately after
intervention in 102 single Palmaz-Schatz stents and 134 directional
atherectomies, 192 (81%) of which had repeat angiographic measurement of
minimal luminal diameter 6 months after the intervention. The immediate
enlargement in luminal diameter produced by the intervention (acute gain)
and the subsequent reduction in luminal diameter from the time of
intervention to 6 months of follow-up (late loss) were calculated. METHODS
AND RESULTS. Luminal diameter increased from 0.69 +/- 0.40 mm to 3.11 +/-
0.64 mm (acute gain, 2.41 +/- 0.64 mm) after intervention, providing an
immediate postprocedure residual stenosis of 1 +/- 14% relative to a
reference diameter of 3.13 +/- 0.65 mm. At 6-month follow-up, the late
luminal diameter was 1.97 +/- 0.92 mm (late loss, 1.13 +/- 0.89 mm),
yielding a late diameter stenosis of 36 +/- 26%. The restenosis rate
(according to the traditional definition of diameter stenosis > or =
50%) was 30%. Multivariable analysis demonstrated that late luminal
diameter (p = 0.02), late percent stenosis (p = 0.04), and restenosis
(according to a > 50% definition, p = 0.04) were each strongly
associated with the luminal diameter present immediately after the
procedure. Whereas late luminal diameter was also influenced by reference
artery size and the vessel treated (left anterior descending versus right
coronary artery), reference vessel size was rejected by the multivariable
models of late percent stenosis and binary restenosis after they were
adjusted for the effect of postprocedure luminal diameter. Once adjusted
for postprocedure luminal diameter, neither late luminal diameter nor late
loss was found to be independently determined by which device was used
(atherectomy versus stents). Rather, late loss was determined independently
by the immediate postprocedure luminal diameter (p = 0.005) and the
postprocedure percent stenosis (p = 0.02). Although late loss thus
increased with acute gain, the net beneficial effect of increased acute
gain was maintained: Late loss was only a fraction (0.47) of acute gain, so
the ability of a larger postprocedure luminal diameter to reduce the
probability of subsequent restenosis was preserved. CONCLUSIONS. This
quantitative model demonstrates that the late coronary lumen diameter and
the probability of restenosis after Palmaz-Schatz stenting or directional
atherectomy are influenced strongly by the lumen diameter present
immediately after the procedure rather than by the specific device used.
Although the influence of a larger acute result on reduced restenosis
appears to be well established in this treatment population, the interplay
among the multiple other biological influences on restenosis limits the
ability to predict the probability of restenosis for the individual patient
based on a large acute result alone. Future studies of restenosis, however,
can further refine this multivariable quantitative model by adjusting for
the effects of other clinical variables, mechanical interventions, or drug
therapies in addition to the clear effect of postprocedure luminal
diameter.
ARTICLES
The importance of acute luminal diameter in determining restenosis after coronary atherectomy or stenting
Charles A. Dana Research Institute, Harvard Medical School, Boston, MA.
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