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Published in: Cardiovascular Intervention and Therapeutics 1/2015

01-01-2015 | Review Article

Histopathology of vascular response to drug-eluting stents: an insight from human autopsy into daily practice

Authors: Masataka Nakano, Renu Virmani

Published in: Cardiovascular Intervention and Therapeutics | Issue 1/2015

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Abstract

Drug-eluting stents (DES) were developed with the primary purpose of inhibiting neointimal overgrowth following percutaneous coronary intervention (PCI). While DES have significantly reduced the rates of restenosis compared with bare metal stent (BMS), they have not completely eliminated it. Moreover, late stent thrombosis (LST), attributed to delayed arterial healing or abnormal vessel responses to DES, have emerged as a major safety concern. Although newer DES or other novel devices are expected to show promising results, the problems in interventional technologies have not been completely resolved. In this review, we will consider the current status of DES in clinical practice and discuss the strengths and limitations of recent advances from the view of histopathology.
Literature
1.
go back to reference Farb A, Sangiorgi G, Carter AJ, Walley VM, Edwards WD, Schwartz RS, Virmani R. Pathology of acute and chronic coronary stenting in humans. Circulation. 1999;99:44–52.PubMedCrossRef Farb A, Sangiorgi G, Carter AJ, Walley VM, Edwards WD, Schwartz RS, Virmani R. Pathology of acute and chronic coronary stenting in humans. Circulation. 1999;99:44–52.PubMedCrossRef
2.
go back to reference Naito M, Stirk CM, Smith EB, Thompson WD. Smooth muscle cell outgrowth stimulated by fibrin degradation products. The potential role of fibrin fragment e in restenosis and atherogenesis. Thromb Res. 2000;98:165–74.PubMedCrossRef Naito M, Stirk CM, Smith EB, Thompson WD. Smooth muscle cell outgrowth stimulated by fibrin degradation products. The potential role of fibrin fragment e in restenosis and atherogenesis. Thromb Res. 2000;98:165–74.PubMedCrossRef
3.
go back to reference Farb A, Weber DK, Kolodgie FD, Burke AP, Virmani R. Morphological predictors of restenosis after coronary stenting in humans. Circulation. 2002;105:2974–80.PubMedCrossRef Farb A, Weber DK, Kolodgie FD, Burke AP, Virmani R. Morphological predictors of restenosis after coronary stenting in humans. Circulation. 2002;105:2974–80.PubMedCrossRef
5.
go back to reference Sata M, Saiura A, Kunisato A, Tojo A, Okada S, Tokuhisa T, Hirai H, Makuuchi M, Hirata Y, Nagai R. Hematopoietic stem cells differentiate into vascular cells that participate in the pathogenesis of atherosclerosis. Nat Med. 2002;8:403–9.PubMedCrossRef Sata M, Saiura A, Kunisato A, Tojo A, Okada S, Tokuhisa T, Hirai H, Makuuchi M, Hirata Y, Nagai R. Hematopoietic stem cells differentiate into vascular cells that participate in the pathogenesis of atherosclerosis. Nat Med. 2002;8:403–9.PubMedCrossRef
6.
go back to reference Farb A, Kolodgie FD, Hwang JY, Burke AP, Tefera K, Weber DK, Wight TN, Virmani R. Extracellular matrix changes in stented human coronary arteries. Circulation. 2004;110:940–7.PubMedCrossRef Farb A, Kolodgie FD, Hwang JY, Burke AP, Tefera K, Weber DK, Wight TN, Virmani R. Extracellular matrix changes in stented human coronary arteries. Circulation. 2004;110:940–7.PubMedCrossRef
7.
go back to reference Kimura T, Yokoi H, Nakagawa Y, Tamura T, Kaburagi S, Sawada Y, Sato Y, Hamasaki N, Nosaka H, et al. Three-year follow-up after implantation of metallic coronary-artery stents. N Engl J Med. 1996;334:561–6.PubMedCrossRef Kimura T, Yokoi H, Nakagawa Y, Tamura T, Kaburagi S, Sawada Y, Sato Y, Hamasaki N, Nosaka H, et al. Three-year follow-up after implantation of metallic coronary-artery stents. N Engl J Med. 1996;334:561–6.PubMedCrossRef
8.
go back to reference Joner M, Finn AV, Farb A, Mont EK, Kolodgie FD, Ladich E, Kutys R, Skorija K, Gold HK, Virmani R. Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk. J Am Coll Cardiol. 2006;48:193–202.PubMedCrossRef Joner M, Finn AV, Farb A, Mont EK, Kolodgie FD, Ladich E, Kutys R, Skorija K, Gold HK, Virmani R. Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk. J Am Coll Cardiol. 2006;48:193–202.PubMedCrossRef
9.
go back to reference Napoli C, de Nigris F, Williams-Ignarro S, Pignalosa O, Sica V, Ignarro LJ. Nitric oxide and atherosclerosis: an update. Nitric Oxide. 2006;15:265–79.PubMedCrossRef Napoli C, de Nigris F, Williams-Ignarro S, Pignalosa O, Sica V, Ignarro LJ. Nitric oxide and atherosclerosis: an update. Nitric Oxide. 2006;15:265–79.PubMedCrossRef
10.
go back to reference Anderson PG, Bajaj RK, Baxley WA, Roubin GS. Vascular pathology of balloon-expandable flexible coil stents in humans. J Am Coll Cardiol. 1992;19:372–81.PubMedCrossRef Anderson PG, Bajaj RK, Baxley WA, Roubin GS. Vascular pathology of balloon-expandable flexible coil stents in humans. J Am Coll Cardiol. 1992;19:372–81.PubMedCrossRef
11.
go back to reference Finn AV, Joner M, Nakazawa G, Kolodgie F, Newell J, John MC, Gold HK, Virmani R. Pathological correlates of late drug-eluting stent thrombosis: strut coverage as a marker of endothelialization. Circulation. 2007;115:2435–41.PubMedCrossRef Finn AV, Joner M, Nakazawa G, Kolodgie F, Newell J, John MC, Gold HK, Virmani R. Pathological correlates of late drug-eluting stent thrombosis: strut coverage as a marker of endothelialization. Circulation. 2007;115:2435–41.PubMedCrossRef
12.
go back to reference Nakazawa G, Finn AV, Joner M, Ladich E, Kutys R, Mont EK, Gold HK, Burke AP, Kolodgie FD, Virmani R. Delayed arterial healing and increased late stent thrombosis at culprit sites after drug-eluting stent placement for acute myocardial infarction patients: an autopsy study. Circulation. 2008;118:1138–45.PubMedCrossRef Nakazawa G, Finn AV, Joner M, Ladich E, Kutys R, Mont EK, Gold HK, Burke AP, Kolodgie FD, Virmani R. Delayed arterial healing and increased late stent thrombosis at culprit sites after drug-eluting stent placement for acute myocardial infarction patients: an autopsy study. Circulation. 2008;118:1138–45.PubMedCrossRef
13.
go back to reference Hwang CW, Wu D, Edelman ER. Physiological transport forces govern drug distribution for stent-based delivery. Circulation. 2001;104:600–5.PubMedCrossRef Hwang CW, Wu D, Edelman ER. Physiological transport forces govern drug distribution for stent-based delivery. Circulation. 2001;104:600–5.PubMedCrossRef
14.
go back to reference Takebayashi H, Mintz GS, Carlier SG, Kobayashi Y, Fujii K, Yasuda T, Costa RA, Moussa I, Dangas GD, Mehran R, Lansky AJ, Kreps E, Collins MB, Colombo A, Stone GW, Leon MB, Moses JW. Nonuniform strut distribution correlates with more neointimal hyperplasia after sirolimus-eluting stent implantation. Circulation. 2004;110:3430–4.PubMedCrossRef Takebayashi H, Mintz GS, Carlier SG, Kobayashi Y, Fujii K, Yasuda T, Costa RA, Moussa I, Dangas GD, Mehran R, Lansky AJ, Kreps E, Collins MB, Colombo A, Stone GW, Leon MB, Moses JW. Nonuniform strut distribution correlates with more neointimal hyperplasia after sirolimus-eluting stent implantation. Circulation. 2004;110:3430–4.PubMedCrossRef
15.
go back to reference Nakano M, Otsuka F, Yahagi K, Sakakura K, Kutys R, Ladich ER, Finn AV, Kolodgie FD, Virmani R. Human autopsy study of drug-eluting stents restenosis: histomorphological predictors and neointimal characteristics. Eur Heart J. 2013;34:3304–13.PubMedCentralPubMedCrossRef Nakano M, Otsuka F, Yahagi K, Sakakura K, Kutys R, Ladich ER, Finn AV, Kolodgie FD, Virmani R. Human autopsy study of drug-eluting stents restenosis: histomorphological predictors and neointimal characteristics. Eur Heart J. 2013;34:3304–13.PubMedCentralPubMedCrossRef
16.
go back to reference Nakazawa G, Otsuka F, Nakano M, Vorpahl M, Yazdani SK, Ladich E, Kolodgie FD, Finn AV, Virmani R. The pathology of neoatherosclerosis in human coronary implants bare-metal and drug-eluting stents. J Am Coll Cardiol. 2011;57:1314–22.PubMedCentralPubMedCrossRef Nakazawa G, Otsuka F, Nakano M, Vorpahl M, Yazdani SK, Ladich E, Kolodgie FD, Finn AV, Virmani R. The pathology of neoatherosclerosis in human coronary implants bare-metal and drug-eluting stents. J Am Coll Cardiol. 2011;57:1314–22.PubMedCentralPubMedCrossRef
17.
go back to reference Skalen K, Gustafsson M, Rydberg EK, Hulten LM, Wiklund O, Innerarity TL, Boren J. Subendothelial retention of atherogenic lipoproteins in early atherosclerosis. Nature. 2002;417:750–4.PubMedCrossRef Skalen K, Gustafsson M, Rydberg EK, Hulten LM, Wiklund O, Innerarity TL, Boren J. Subendothelial retention of atherogenic lipoproteins in early atherosclerosis. Nature. 2002;417:750–4.PubMedCrossRef
18.
go back to reference Windecker S, Remondino A, Eberli FR, Juni P, Raber L, Wenaweser P, Togni M, Billinger M, Tuller D, Seiler C, Roffi M, Corti R, Sutsch G, Maier W, Luscher T, Hess OM, Egger M, Meier B. Sirolimus-eluting and paclitaxel-eluting stents for coronary revascularization. N Engl J Med. 2005;353:653–62.PubMedCrossRef Windecker S, Remondino A, Eberli FR, Juni P, Raber L, Wenaweser P, Togni M, Billinger M, Tuller D, Seiler C, Roffi M, Corti R, Sutsch G, Maier W, Luscher T, Hess OM, Egger M, Meier B. Sirolimus-eluting and paclitaxel-eluting stents for coronary revascularization. N Engl J Med. 2005;353:653–62.PubMedCrossRef
19.
go back to reference Simsek C, Magro M, Boersma E, Onuma Y, Nauta S, Daemen J, Gaspersz M, van Geuns RJ, van der Giessen W, van Domburg R, Serruys P. Comparison of six-year clinical outcome of sirolimus- and paclitaxel-eluting stents to bare-metal stents in patients with st-segment elevation myocardial infarction: an analysis of the research (rapamycin-eluting stent evaluated at Rotterdam cardiology hospital) and t-search (taxus stent evaluated at Rotterdam cardiology hospital) registries. J Invasive Cardiol. 2011;23:336–41.PubMed Simsek C, Magro M, Boersma E, Onuma Y, Nauta S, Daemen J, Gaspersz M, van Geuns RJ, van der Giessen W, van Domburg R, Serruys P. Comparison of six-year clinical outcome of sirolimus- and paclitaxel-eluting stents to bare-metal stents in patients with st-segment elevation myocardial infarction: an analysis of the research (rapamycin-eluting stent evaluated at Rotterdam cardiology hospital) and t-search (taxus stent evaluated at Rotterdam cardiology hospital) registries. J Invasive Cardiol. 2011;23:336–41.PubMed
20.
go back to reference Nakazawa G, Finn AV, Vorpahl M, Ladich ER, Kolodgie FD, Virmani R. Coronary responses and differential mechanisms of late stent thrombosis attributed to first-generation sirolimus- and paclitaxel-eluting stents. J Am Coll Cardiol. 2011;57:390–8.PubMedCrossRef Nakazawa G, Finn AV, Vorpahl M, Ladich ER, Kolodgie FD, Virmani R. Coronary responses and differential mechanisms of late stent thrombosis attributed to first-generation sirolimus- and paclitaxel-eluting stents. J Am Coll Cardiol. 2011;57:390–8.PubMedCrossRef
21.
go back to reference Nakano M, Yahagi K, Otsuka F, Sakakura K, Finn AV, Kutys R, Ladich E, Fowler DR, Joner M, Virmani R. Causes of early stent thrombosis in patients presenting with acute coronary syndrome: an ex vivo human autopsy study. J Am Coll Cardiol. 2014;63:2510–20. Nakano M, Yahagi K, Otsuka F, Sakakura K, Finn AV, Kutys R, Ladich E, Fowler DR, Joner M, Virmani R. Causes of early stent thrombosis in patients presenting with acute coronary syndrome: an ex vivo human autopsy study. J Am Coll Cardiol. 2014;63:2510–20.
22.
go back to reference Virmani R, Guagliumi G, Farb A, Musumeci G, Grieco N, Motta T, Mihalcsik L, Tespili M, Valsecchi O, Kolodgie FD. Localized hypersensitivity and late coronary thrombosis secondary to a sirolimus-eluting stent: should we be cautious? Circulation. 2004;109:701–5.PubMedCrossRef Virmani R, Guagliumi G, Farb A, Musumeci G, Grieco N, Motta T, Mihalcsik L, Tespili M, Valsecchi O, Kolodgie FD. Localized hypersensitivity and late coronary thrombosis secondary to a sirolimus-eluting stent: should we be cautious? Circulation. 2004;109:701–5.PubMedCrossRef
23.
go back to reference Farb A, Heller PF, Shroff S, Cheng L, Kolodgie FD, Carter AJ, Scott DS, Froehlich J, Virmani R. Pathological analysis of local delivery of paclitaxel via a polymer-coated stent. Circulation. 2001;104:473–9.PubMedCrossRef Farb A, Heller PF, Shroff S, Cheng L, Kolodgie FD, Carter AJ, Scott DS, Froehlich J, Virmani R. Pathological analysis of local delivery of paclitaxel via a polymer-coated stent. Circulation. 2001;104:473–9.PubMedCrossRef
24.
go back to reference Park DW, Hong MK, Mintz GS, Lee CW, Song JM, Han KH, Kang DH, Cheong SS, Song JK, Kim JJ, Weissman NJ, Park SW, Park SJ. Two-year follow-up of the quantitative angiographic and volumetric intravascular ultrasound analysis after nonpolymeric paclitaxel-eluting stent implantation: late “catch-up” phenomenon from aspect study. J Am Coll Cardiol. 2006;48:2432–9.PubMedCrossRef Park DW, Hong MK, Mintz GS, Lee CW, Song JM, Han KH, Kang DH, Cheong SS, Song JK, Kim JJ, Weissman NJ, Park SW, Park SJ. Two-year follow-up of the quantitative angiographic and volumetric intravascular ultrasound analysis after nonpolymeric paclitaxel-eluting stent implantation: late “catch-up” phenomenon from aspect study. J Am Coll Cardiol. 2006;48:2432–9.PubMedCrossRef
25.
go back to reference Nakagawa Y, Kimura T, Morimoto T, Nomura M, Saku K, Haruta S, Muramatsu T, Nobuyoshi M, Kadota K, Fujita H, Tatami R, Shiode N, Nishikawa H, Shibata Y, Miyazaki S, Murata Y, Honda T, Kawasaki T, Doi O, Hiasa Y, Hayashi Y, Matsuzaki M, Mitsudo K. Incidence and risk factors of late target lesion revascularization after sirolimus-eluting stent implantation (3-year follow-up of the j-cypher registry). Am J Cardiol. 2010;106:329–36.PubMedCrossRef Nakagawa Y, Kimura T, Morimoto T, Nomura M, Saku K, Haruta S, Muramatsu T, Nobuyoshi M, Kadota K, Fujita H, Tatami R, Shiode N, Nishikawa H, Shibata Y, Miyazaki S, Murata Y, Honda T, Kawasaki T, Doi O, Hiasa Y, Hayashi Y, Matsuzaki M, Mitsudo K. Incidence and risk factors of late target lesion revascularization after sirolimus-eluting stent implantation (3-year follow-up of the j-cypher registry). Am J Cardiol. 2010;106:329–36.PubMedCrossRef
26.
go back to reference Chieffo A, Foglieni C, Nodari RL, Briguori C, Sangiorgi G, Latib A, Montorfano M, Airoldi F, Michev I, Carlino M, Colombo A, Maseri A. Histopathology of clinical coronary restenosis in drug-eluting versus bare metal stents. Am J Cardiol. 2009;104:1660–7.PubMedCrossRef Chieffo A, Foglieni C, Nodari RL, Briguori C, Sangiorgi G, Latib A, Montorfano M, Airoldi F, Michev I, Carlino M, Colombo A, Maseri A. Histopathology of clinical coronary restenosis in drug-eluting versus bare metal stents. Am J Cardiol. 2009;104:1660–7.PubMedCrossRef
27.
go back to reference Ishida T, Tanaka K. Effects of fibrin and fibrinogen-degradation products on the growth of rabbit aortic smooth muscle cells in culture. Atherosclerosis. 1982;44:161–74.PubMedCrossRef Ishida T, Tanaka K. Effects of fibrin and fibrinogen-degradation products on the growth of rabbit aortic smooth muscle cells in culture. Atherosclerosis. 1982;44:161–74.PubMedCrossRef
28.
go back to reference Moses JW, Leon MB, Popma JJ, Fitzgerald PJ, Holmes DR, O’Shaughnessy C, Caputo RP, Kereiakes DJ, Williams DO, Teirstein PS, Jaeger JL, Kuntz RE. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med. 2003;349:1315–23.PubMedCrossRef Moses JW, Leon MB, Popma JJ, Fitzgerald PJ, Holmes DR, O’Shaughnessy C, Caputo RP, Kereiakes DJ, Williams DO, Teirstein PS, Jaeger JL, Kuntz RE. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med. 2003;349:1315–23.PubMedCrossRef
29.
go back to reference Stone GW, Ellis SG, Cox DA, Hermiller J, O’Shaughnessy C, Mann JT, Turco M, Caputo R, Bergin P, Greenberg J, Popma JJ, Russell ME. A polymer-based, paclitaxel-eluting stent in patients with coronary artery disease. N Engl J Med. 2004;350:221–31.PubMedCrossRef Stone GW, Ellis SG, Cox DA, Hermiller J, O’Shaughnessy C, Mann JT, Turco M, Caputo R, Bergin P, Greenberg J, Popma JJ, Russell ME. A polymer-based, paclitaxel-eluting stent in patients with coronary artery disease. N Engl J Med. 2004;350:221–31.PubMedCrossRef
30.
go back to reference Palmerini T, Biondi-Zoccai G, Della Riva D, Stettler C, Sangiorgi D, D’Ascenzo F, Kimura T, Briguori C, Sabate M, Kim HS, De Waha A, Kedhi E, Smits PC, Kaiser C, Sardella G, Marullo A, Kirtane AJ, Leon MB, Stone GW. Stent thrombosis with drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. Lancet. 2012;379:1393–402.PubMedCrossRef Palmerini T, Biondi-Zoccai G, Della Riva D, Stettler C, Sangiorgi D, D’Ascenzo F, Kimura T, Briguori C, Sabate M, Kim HS, De Waha A, Kedhi E, Smits PC, Kaiser C, Sardella G, Marullo A, Kirtane AJ, Leon MB, Stone GW. Stent thrombosis with drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. Lancet. 2012;379:1393–402.PubMedCrossRef
31.
go back to reference Otsuka F, Vorpahl M, Nakano M, Foerst J, Newell JB, Sakakura K, Kutys R, Ladich E, Finn AV, Kolodgie FD, Virmani R. Pathology of second-generation everolimus-eluting stents versus first-generation sirolimus- and paclitaxel-eluting stents in humans. Circulation. 2014;129:211–23.PubMedCentralPubMedCrossRef Otsuka F, Vorpahl M, Nakano M, Foerst J, Newell JB, Sakakura K, Kutys R, Ladich E, Finn AV, Kolodgie FD, Virmani R. Pathology of second-generation everolimus-eluting stents versus first-generation sirolimus- and paclitaxel-eluting stents in humans. Circulation. 2014;129:211–23.PubMedCentralPubMedCrossRef
32.
go back to reference Serruys PW, Onuma Y, Garcia-Garcia HM, Muramatsu T, van Geuns RJ, de Bruyne B, Dudek D, Thuesen L, Smits PC, Chevalier B, McClean D, Koolen J, Windecker S, Whitbourn R, Meredith I, Dorange C, Veldhof S, Hebert KM, Rapoza R, Ormiston JA. Dynamics of vessel wall changes following the implantation of the absorb everolimus-eluting bioresorbable vascular scaffold: a multi-imaging modality study at 6, 12, 24 and 36 months. Eurointervention. 2014;9:1271–84.PubMedCrossRef Serruys PW, Onuma Y, Garcia-Garcia HM, Muramatsu T, van Geuns RJ, de Bruyne B, Dudek D, Thuesen L, Smits PC, Chevalier B, McClean D, Koolen J, Windecker S, Whitbourn R, Meredith I, Dorange C, Veldhof S, Hebert KM, Rapoza R, Ormiston JA. Dynamics of vessel wall changes following the implantation of the absorb everolimus-eluting bioresorbable vascular scaffold: a multi-imaging modality study at 6, 12, 24 and 36 months. Eurointervention. 2014;9:1271–84.PubMedCrossRef
33.
go back to reference Serruys PW, Ormiston JA, Onuma Y, Regar E, Gonzalo N, Garcia-Garcia HM, Nieman K, Bruining N, Dorange C, Miquel-Hebert K, Veldhof S, Webster M, Thuesen L, Dudek D. A bioabsorbable everolimus-eluting coronary stent system (absorb): 2-year outcomes and results from multiple imaging methods. Lancet. 2009;373:897–910.PubMedCrossRef Serruys PW, Ormiston JA, Onuma Y, Regar E, Gonzalo N, Garcia-Garcia HM, Nieman K, Bruining N, Dorange C, Miquel-Hebert K, Veldhof S, Webster M, Thuesen L, Dudek D. A bioabsorbable everolimus-eluting coronary stent system (absorb): 2-year outcomes and results from multiple imaging methods. Lancet. 2009;373:897–910.PubMedCrossRef
34.
go back to reference Finn AV, Nakazawa G, Joner M, Kolodgie FD, Mont EK, Gold HK, Virmani R. Vascular responses to drug eluting stents: importance of delayed healing. Arterioscler Thromb Vasc Biol. 2007;27:1500–10. Finn AV, Nakazawa G, Joner M, Kolodgie FD, Mont EK, Gold HK, Virmani R. Vascular responses to drug eluting stents: importance of delayed healing. Arterioscler Thromb Vasc Biol. 2007;27:1500–10.
Metadata
Title
Histopathology of vascular response to drug-eluting stents: an insight from human autopsy into daily practice
Authors
Masataka Nakano
Renu Virmani
Publication date
01-01-2015
Publisher
Springer Japan
Published in
Cardiovascular Intervention and Therapeutics / Issue 1/2015
Print ISSN: 1868-4300
Electronic ISSN: 1868-4297
DOI
https://doi.org/10.1007/s12928-014-0281-5

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