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(Circulation. 2007;116:910-916.)
© 2007 American Heart Association, Inc.

Interventional Cardiology

Serial Angioscopic Evidence of Incomplete Neointimal Coverage After Sirolimus-Eluting Stent Implantation

Comparison With Bare-Metal Stents

Masaki Awata, MD; Jun-ichi Kotani, MD, PhD; Masaaki Uematsu, MD, PhD; Takakazu Morozumi, MD, PhD; Tetsuya Watanabe, MD, PhD; Toshinari Onishi, MD; Osamu Iida, MD; Fusako Sera, MD; Shinsuke Nanto, MD, PhD; Masatsugu Hori, MD, PhD; Seiki Nagata, MD, PhD

From the Cardiovascular Division, Kansai Rosai Hospital (M.A., J.K., M.U., T.M., T.W., T.O., O.I., F.S., S. Nanto, S. Nagata), Amagasaki, Japan, and Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine (M.H.), Suita, Japan.

Correspondence to Jun-ichi Kotani, MD, PhD, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871 Japan. E-mail shamallv8{at}aol.com

Received September 21, 2006; accepted June 14, 2007.

Background— The time course of neointimal formation after stent implantation has not been studied extensively by angioscopy in the drug-eluting stent era.

Methods and Results— Serial angioscopic findings at first follow-up (3.6±1.1 months), second follow-up (10.5±1.6 months), and third follow-up (21.2±2.2 months) after stent implantation were compared between sirolimus-eluting stents (SES, n=17) and bare-metal stents (BMS, n=11). Neointimal coverage, thrombus, and presence of yellow plaques underneath the stents were assessed. Neointimal coverage was graded as follows: grade 0, stent struts were fully visible; grade 1, struts bulged into the lumen, although they were covered; grade 2, struts were embedded by the neointima but were seen translucently; or grade 3, struts were fully embedded and invisible. Neointimal coverage was remarkably different between SES and BMS at each follow-up point. Neointimal coverage grade was 1.1±0.5 in SES versus 2.9±0.3 in BMS at the first follow-up (P<0.0001), 1.1±0.5 in SES versus 3.0±0.0 in BMS (P<0.0001) at the second follow-up, and 1.3±0.5 in SES versus 3.0±0.0 in BMS at the third follow-up (P=0.0009). No significant serial changes in coverage grade were noted in the BMS group, whereas coverage grade slightly but significantly increased at the third follow-up in the SES group (P<0.05). Thrombi were detected in 4 SES: a red thrombus was seen from the first to the third follow-up in 2; another was detected only at the third follow-up; and the fourth was seen at the first follow-up but disappeared at the second follow-up, associated with a new white thrombus despite dual antiplatelet therapy. Yellow plaques had disappeared by the time of the second follow-up in BMS. In contrast, yellow plaques were exposed in 71% of SES at the first follow-up and remained exposed until the third follow-up. Neointimal coverage grades correlated with thrombi (P=0.002) and with yellow plaques (P<0.0001).

Conclusions— Serial angioscopic findings up to 2 years after SES implantation were markedly different from those after BMS. Neointimal coverage was completed by 3 to 6 months in BMS. In contrast, SES demonstrated the presence of thrombi and yellow plaques even as much as 2 years after implantation.

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