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Difference of Tissue Characteristics Between Early and Very Late Restenosis Lesions After Bare-Metal Stent Implantation: An Optical Coherence Tomography Study

Background— Although in-stent restenosis (ISR) after bare-metal stent (BMS) implantation peaks in the early phase, very late (VL) ISR occasionally is observed beyond a few years after BMS implantation. To date, this mechanism has not been fully clarified. Methods and Results— We compared the morphological characteristics of VL-ISR (>5 years, without restenosis within the first year) (n=43) to those of early (E) ISR (within the first year) (n=39) using optical coherence tomography (OCT). Qualitative restenotic tissue analysis included assessment of tissue structure (homogeneous or heterogeneous), presence of microvessels, disrupted intima with cavity, and intraluminal material and was performed at every 1-mm slice of the entire stent. The proportions of cross-sections with heterogeneous intima in the entire stent was significantly higher in the VL-ISR group compared to the E-ISR group (60.5±28.5% versus 5.8±11.5%, P<0.0001), with heterogeneous intima being more frequently observed at the minimum lumen area site in the VL-ISR group (90.7% versus 17.9%, P<0.0001). Disrupted intima with cavity and intraluminal material also were observed more frequently in the VL-ISR group for the entire stent (18.6% versus 0%, 20.9% versus 2.6%, P<0.03) as well as at the minimum lumen area site (13.9% versus 0%,16.2% versus 0%, P<0.03). Conclusions— The morphological characteristics of restenotic tissue in VL-ISR were different from those in E-ISR and similar to atherosclerotic plaque. In BMS, progression of the atherosclerotic process within neointima after stent implantation may be associated with VL-ISR.