(Circulation. 1997;95:1366-1369.)
© 1997 American Heart Association, Inc.
Articles |
Increased Restenosis in Diabetes Mellitus After Coronary Interventions Is Due to Exaggerated Intimal Hyperplasia
A Serial Intravascular Ultrasound Study
the Intravascular Imaging and Cardiac Catheterization Laboratories, Washington (DC) Hospital Center.
Correspondence to Martin B. Leon, MD, Director of Research, Washington Cardiology Center, 110 Irving St NW, Suite 4B1, Washington, DC 20010.
Background The increased risk of restenosis after catheter-based coronary interventions in diabetic patients has not been determined. Intravascular ultrasound (IVUS) has shown that the decrease in arterial area is responsible for most of the late lumen loss in nonstented lesions and that intimal hyperplasia is responsible for all of the late lumen loss in stented lesions.
Methods and Results Serial (postintervention and follow-up at 5.6±3.3 months) IVUS was used to study 251 native coronary lesions in 241 patients; 63 patients had treated diabetes mellitus (oral hypoglycemic drugs or insulin). Interventional procedures included percutaneous transluminal coronary angioplasty, directional or rotational atherectomy, excimer laser angioplasty, or Palmaz-Schatz stents. The external elastic membrane (EEM), stent, and lumen areas were measured. The plaque+media (P+M) area in nonstented lesions was calculated as EEM minus lumen area, and the intimal hyperplasia (IH) area in stented lesions was calculated as stent minus lumen area. The anatomic slice selected for serial analysis had an axial location within the target lesion at the smallest follow-up lumen area. Nonstented lesions in diabetics and nondiabetics had a similar decrease in EEM cross-sectional area (CSA; 1.9±2.8 versus 1.8±4.2 mm2; P=.6350). However, nonstented lesions in diabetics had a greater increase in P=M CSA (1.3±2.8 versus 0.6±2.5 mm2, P=.0720), and the increase in P=M CSA contributed a greater percentage to the decrease in lumen CSA. In stented lesions, the decrease in lumen CSA (5.2±2.5 versus 2.0±2.3 mm2) and the increase in IH CSA (5.0±2.8 versus 1.8±2.0 mm2) were greater in diabetics than nondiabetics (P=.0009 and P=.0007, respectively). These findings were even more striking in (nonstented and stented) restenotic lesions.
Conclusions Serial IVUS analysis showed that the main reason for increased restenosis in diabetes mellitus was exaggerated intimal hyperplasia in both stented and nonstented lesions.
Key Words: diabetes mellitus • angioplasty • stents • remodeling • coronary disease
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A. Abizaid, M. A. Costa, M. Centemero, A. S. Abizaid, V. M.G. Legrand, R. V. Limet, G. Schuler, F. W. Mohr, W. Lindeboom, A. G.M.R. Sousa, et al. Clinical and Economic Impact of Diabetes Mellitus on Percutaneous and Surgical Treatment of Multivessel Coronary Disease Patients: Insights From the Arterial Revascularization Therapy Study (ARTS) Trial Circulation, July 31, 2001; 104(5): 533 - 538. [Abstract] [Full Text] [PDF]
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C. Indolfi, D. Torella, L. Cavuto, A. M. Davalli, C. Coppola, G. Esposito, M. V. Carriero, A. Rapacciuolo, E. Di Lorenzo, E. Stabile, et al. Effects of Balloon Injury on Neointimal Hyperplasia in Streptozotocin-Induced Diabetes and in Hyperinsulinemic Nondiabetic Pancreatic Islet-Transplanted Rats Circulation, June 19, 2001; 103(24): 2980 - 2986. [Abstract] [Full Text] [PDF]
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A. Moustapha, A. R. Assali, S. Sdringola, W. K. Vaughn, R. D. Fish, O. Rosales, G. Schroth, Z. Krajcer, R. W. Smalling, and H. V. Anderson Percutaneous and surgical interventions for in-stent restenosis: long-term outcomes and effect of diabetes mellitus J. Am. Coll. Cardiol., June 1, 2001; 37(7): 1877 - 1882. [Abstract] [Full Text] [PDF]
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F. Ledru, P. Ducimetiere, S. Battaglia, D. Courbon, F. Beverelli, L. Guize, J.-L.e. Guermonprez, and B. Diebold New diagnostic criteria for diabetes and coronary artery disease: insights from an angiographic study J. Am. Coll. Cardiol., May 1, 2001; 37(6): 1543 - 1550. [Abstract] [Full Text] [PDF]
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J. L. Hall, J. C. Chatham, H. Eldar-Finkelman, and G. H. Gibbons Upregulation of Glucose Metabolism During Intimal Lesion Formation Is Coupled to the Inhibition of Vascular Smooth Muscle Cell Apoptosis: Role of GSK3{beta} Diabetes, May 1, 2001; 50(5): 1171 - 1179. [Abstract] [Full Text]
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M. Nakamura, P. G. Yock, H. N. Bonneau, K. Kitamura, T. Aizawa, H. Tamai, P. J. Fitzgerald, and Y. Honda Impact of Peri-Stent Remodeling on Restenosis : A Volumetric Intravascular Ultrasound Study Circulation, May 1, 2001; 103(17): 2130 - 2132. [Abstract] [Full Text] [PDF]
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M. Matsa, Y. Paz, J. Gurevitch, I. Shapira, A. Kramer, D. Pevny, and R. Mohr Bilateral skeletonized internal thoracic artery grafts in patients with diabetes mellitus J. Thorac. Cardiovasc. Surg., April 1, 2001; 121(4): 668 - 674. [Abstract] [Full Text] [PDF]
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W. A. Hsueh, S. Jackson, and R. E. Law Control of Vascular Cell Proliferation and Migration by PPAR-{gamma}: A new approach to the macrovascular complications of diabetes Diabetes Care, February 1, 2001; 24(2): 392 - 397. [Abstract] [Full Text]
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A. Endo, H. Hirayama, O. Yoshida, T. Arakawa, T. Akima, T. Yamada, and M. Nanasato Arterial remodeling influences the development of intimal hyperplasia after stent implantation J. Am. Coll. Cardiol., January 1, 2001; 37(1): 70 - 75. [Abstract] [Full Text] [PDF]
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T. Takagi, T. Akasaka, A. Yamamuro, Y. Honda, T. Hozumi, S. Morioka, and K. Yoshida Troglitazone reduces neointimal tissue proliferation after coronary stent implantation in patients with non-insulin dependent diabetes mellitus: A serial intravascular ultrasound study J. Am. Coll. Cardiol., November 1, 2000; 36(5): 1529 - 1535. [Abstract] [Full Text] [PDF]
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J. L. Hall, C. M. Matter, X. Wang, and G. H. Gibbons Hyperglycemia Inhibits Vascular Smooth Muscle Cell Apoptosis Through a Protein Kinase C-Dependent Pathway Circ. Res., September 29, 2000; 87(7): 574 - 580. [Abstract] [Full Text] [PDF]
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T. Takagi, K. Yoshida, T. Akasaka, S. Kaji, T. Kawamoto, Y. Honda, A. Yamamuro, T. Hozumi, and S. Morioka Hyperinsulinemia during oral glucose tolerance test is associated with increased neointimal tissue proliferation after coronary stent implantation in nondiabetic patients: A serial intravascular ultrasound study J. Am. Coll. Cardiol., September 1, 2000; 36(3): 731 - 738. [Abstract] [Full Text] [PDF]
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A. Chajara, M. Raoudi, B. Delpech, M. Leroy, J. P. Basuyau, and H. Levesque Increased Hyaluronan and Hyaluronidase Production and Hyaluronan Degradation in Injured Aorta of Insulin-Resistant Rats Arterioscler Thromb Vasc Biol, June 1, 2000; 20(6): 1480 - 1487. [Abstract] [Full Text] [PDF]
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D. Hasdai, C. B. Granger, S. S. Srivatsa, D. A. Criger, S. G. Ellis, R. M. Califf, E. J. Topol, and D. R. Holmes Jr. Diabetes mellitus and outcome after primary coronary angioplasty for acute myocardial infarction: lessons from the GUSTO-IIb angioplasty substudy J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1502 - 1512. [Abstract] [Full Text] [PDF]
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J. Schofer, M. Schluter, T. Rau, F. Hammer, N. Haag, and D. G. Mathey Influence of treatment modality on angiographic outcome after coronary stenting in diabetic patients: a controlled study J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1554 - 1559. [Abstract] [Full Text] [PDF]
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M. Gyongyosi, P. Yang, A. Khorsand, D. Glogar, on behalf of the Austrian Wiktor Stent Study Group, and European Paragon Stent Investigators Longitudinal straightening effect of stents is an additional predictor for major adverse cardiac events J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1580 - 1589. [Abstract] [Full Text] [PDF]
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C. Indolfi, A. Cioppa, E. Stabile, E. Di Lorenzo, G. Esposito, A. Pisani, A. Leccia, L. Cavuto, A. M. Stingone, A. Chieffo, et al. Effects of hydroxymethylglutaryl coenzyme A reductase inhibitor simvastatin on smooth muscle cell proliferation in vitro and neointimal formation in vivo after vascular injury J. Am. Coll. Cardiol., January 1, 2000; 35(1): 214 - 221. [Abstract] [Full Text] [PDF]
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S. P. Marso, A. M. Lincoff, S. G. Ellis, D. L. Bhatt, J.-F. Tanguay, N. S. Kleiman, T. Hammoud, J. E. Booth, S. K. Sapp, and E. J. Topol Optimizing the Percutaneous Interventional Outcomes for Patients With Diabetes Mellitus : Results of the EPISTENT (Evaluation of Platelet IIb/IIIa Inhibitor for Stenting Trial) Diabetic Substudy Circulation, December 21, 1999; 100(25): 2477 - 2484. [Abstract] [Full Text] [PDF]
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P. R. Moreno, J. T. Fallon, A. M. Murcia, M. N. Leon, H. Simosa, V. Fuster, and I. F. Palacios Tissue characteristics of restenosis after percutaneous transluminal coronary angioplasty in diabetic patients J. Am. Coll. Cardiol., October 1, 1999; 34(4): 1045 - 1049. [Abstract] [Full Text] [PDF]
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A. J. Taylor, A. P. Burke, A. Farb, P. Yousefi, G. T. Malcom, J. Smialek, and R. Virmani Arterial remodeling in the left coronary system: The role of high-density lipoprotein cholesterol J. Am. Coll. Cardiol., September 1, 1999; 34(3): 760 - 767. [Abstract] [Full Text] [PDF]
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E. Van Belle, K. Abolmaali, C. Bauters, E. P. McFadden, J.-M. Lablanche, and M. E. Bertrand Restenosis, late vessel occlusion and left ventricular function six months after balloon angioplasty in diabetic patients J. Am. Coll. Cardiol., August 1, 1999; 34(2): 476 - 485. [Abstract] [Full Text] [PDF]
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S. Elezi, A. Kastrati, J.u. Pache, A. Wehinger, M. Hadamitzky, J. Dirschinger, F.-J. Neumann, and A. Schomig Diabetes mellitus and the clinical and angiographic outcome after coronary stent placement J. Am. Coll. Cardiol., December 1, 1998; 32(7): 1866 - 1873. [Abstract] [Full Text] [PDF]
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E. A. de Vrey, G. S. Mintz, C. von Birgelen, T. Kimura, M. Noboyoshi, J. J. Popma, P. W. Serruys, and M. B. Leon Serial volumetric (three-dimensional) intravascular ultrasound analysis of restenosis after directional coronary atherectomy J. Am. Coll. Cardiol., December 1, 1998; 32(7): 1874 - 1880. [Abstract] [Full Text] [PDF]
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Y. Nishimoto, Y. Miyazaki, Y. Toki, R. Murakami, M. Shinoda, A. Fukushima, and H. Kanayama Enhanced secretion of insulin plays a role in the development of atherosclerosis and restenosis of coronary arteries: elective percutaneous transluminal coronary angioplasty in patients with effort angina J. Am. Coll. Cardiol., November 15, 1998; 32(6): 1624 - 1629. [Abstract] [Full Text] [PDF]
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S. Elezi, A. Kastrati, F.-J. Neumann, M. Hadamitzky, J. Dirschinger, and A. Schomig Vessel Size and Long-Term Outcome After Coronary Stent Placement Circulation, November 3, 1998; 98(18): 1875 - 1880. [Abstract] [Full Text] [PDF]
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A. Abizaid, R. Kornowski, G. S. Mintz, M. K. Hong, A. S. Abizaid, R. Mehran, A. D. Pichard, K. M. Kent, L. F. Satler, H. Wu, et al. The influence of diabetes mellitus on acute and late clinical outcomes following coronary stent implantation J. Am. Coll. Cardiol., September 1, 1998; 32(3): 584 - 589. [Abstract] [Full Text] [PDF]
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A. J. Lansky, G. S. Mintz, J. J. Popma, A. D. Pichard, K. M. Kent, L. F. Satler, D. S. Baim, R. E. Kuntz, C. Simonton, R. M. Bersin, et al. Remodeling after directional coronary atherectomy (with and without adjunct percutaneous transluminal coronary angioplasty): a serial angiographic and intravascular ultrasound analysis from the optimal atherectomy restenosis study J. Am. Coll. Cardiol., August 1, 1998; 32(2): 329 - 337. [Abstract] [Full Text] [PDF]
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S. G. Ellis and C. R. Narins Problem of Angioplasty in Diabetics Circulation, September 16, 1997; 96(6): 1707 - 1710. [Full Text]
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S. Uemura, H. Matsushita, W. Li, A. J. Glassford, T. Asagami, K.-H. Lee, D. G. Harrison, and P. S. Tsao Diabetes Mellitus Enhances Vascular Matrix Metalloproteinase Activity : Role of Oxidative Stress Circ. Res., June 22, 2001; 88(12): 1291 - 1298. [Abstract] [Full Text] [PDF]
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K. E. Kip, E. L. Alderman, M. G. Bourassa, M. M. Brooks, L. Schwartz, D. R. Holmes Jr, R. M. Califf, P. L. Whitlow, B. R. Chaitman, and K. M. Detre Differential Influence of Diabetes Mellitus on Increased Jeopardized Myocardium After Initial Angioplasty or Bypass Surgery: Bypass Angioplasty Revascularization Investigation Circulation, April 23, 2002; 105(16): 1914 - 1920. [Abstract] [Full Text] [PDF]
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