(Circulation. 2000;102:e111.)
© 2000 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Positive Remodeling, Regression of In-Stent Neointimal Hyperplasia, and Late Stent Malapposition in the Absence of Brachytherapy
From the Intravascular Ultrasound Imaging and Cardiac Catheterization Laboratories, Washington Hospital Center, Washington, DC.
Correspondence to Gary S. Mintz, MD, 110 Irving St NW, Suite 4B1, Washington, DC 20010. E-mail gsm1{at}mhg.edu
A 50-year-old white man
presented with in-stent restenosis in April 1998. He
had undergone angioplasty with stent implantation for a lesion in the
right coronary artery in December 1977, when he was 29 years
old. At that time, he was enrolled in a placebo-controlled,
randomized trial of 
-irradiation to prevent recurrent in-stent
restenosis (Washington Radiation In-Stent Restenosis Trial
[WRIST]). This included an intravascular ultrasound substudy.
After the dwell time and at follow-up, imaging was performed using a
30-MHz single-element, mechanically rotating transducer (SCIMED/Boston
Scientific Corporation) and automated pullback (0.5 mm/s) after
the administration of 200 µg of intracoronary
nitroglycerin.
In December 1998, recurrence occurred at the proximal
portion of the stent; however, the distal portion of the stent (Figure
)
showed (1) positive remodeling (an increase in external elastic
membrane cross-sectional area from 32.8 to 39.0
mm2), (2) a reduction and virtual elimination of
intrastent neointimal hyperplasia, and (3) late
stent–arterial wall malapposition.
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Positive remodeling, regression of neointimal hyperplasia, and late malapposition have been associated with brachytherapy. However, this patient was randomized to the placebo arm of the study (confirmed by the procedural logs of both the radiation physicist and the radiation safety officer). Although it is our experience that the constellation of these 3 findings (positive remodeling, regression of intimal hyperplasia, and late malapposition) are extremely unusual in the absence of brachytherapy, this case illustrates the importance of control groups, especially when new treatment strategies (ie, brachytherapy) are being evaluated in a small number of patients using new imaging modalities.
Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
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