Generalized model of restenosis after conventional balloon angioplasty, stenting and directional atherectomy

Charles A. Dana Research Institute, Harvard Medical School, Boston, Massachusetts.

OBJECTIVES. This study was designed to extend the results of a quantitative model originally developed for restenosis after stenting or atherectomy to include restenosis after conventional balloon angioplasty. BACKGROUND. We have previously described a continuous regression model that explains late (6-month) lumen narrowing as the difference between the immediate gain and the subsequent normally distributed late loss in lumen diameter after Palmaz-Schatz stenting or directional atherectomy. METHODS. Lumen diameter was measured immediately before and after coronary intervention on 524 consecutive lesions including those treated by Palmaz-Schatz stenting (102), directional atherectomy (134) and conventional balloon angioplasty (288). Of these lesions, 475 (91%) underwent follow-up angiography 3 to 6 months after treatment. The immediate increase in lumen diameter produced by the intervention (immediate gain) and the subsequent reduction in lumen diameter between the time of intervention to follow-up angiography (late loss) were examined. Association between demographic or angiographic variables and continuous measures of restenosis (late lumen diameter or late percent stenosis) was tested with linear regression techniques; a traditional binary measure of restenosis (late diameter stenosis > or = 50%) was evaluated with logistic regression analysis. RESULTS. Regression models relating late lumen diameter to the immediate lumen result were successfully fitted to all segments studied. According to these models, three indexes of restenosis (late lumen diameter, late percent stenosis and binary restenosis) were found to depend solely on the immediate lumen diameter after the procedure and the immediate residual percent stenosis, but not on the specific intervention used. Moreover, the late loss in lumen diameter was found to vary directly with the immediate gain provided by an intervention, and the "loss index" (a measure that corrects for differences in immediate gain) was uniform among all three interventions. CONCLUSIONS. The quantitative model originally developed for restenosis after stenting or atherectomy may thus be generalized to include conventional balloon angioplasty. It shows that the apparent differences in restenosis among the three interventions studied are due solely to differences in the immediate result provided and not to differences in the behavior of subsequent late loss. Moreover, although the late loss in lumen diameter was found to correlate with differences in the immediate gain provided by an intervention, the "loss index" (a measure that corrects for differences in acute gain) was uniform across all three interventions. It is thus the immediate result (and not the procedure used to obtain that result) that determines late outcome after coronary intervention.

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				C. R. Narins, D. R. Holmes Jr, and E. J. Topol A Call for Provisional Stenting : The Balloon Is Back! Circulation, April 7, 1998; 97(13): 1298 - 1305. [Full Text] [PDF]

				J Abe, J Deguchi, Y Takuwa, K Hara, Y Ikari, T Tamura, M Ohno, and K Kurokawa Tyrosine phosphorylation of platelet derived growth factor beta  receptors in coronary artery lesions: implications for vascular remodelling after directional coronary atherectomy and unstable angina pectoris Heart, April 1, 1998; 79(4): 400 - 406. [Abstract] [Full Text]

				B. MEIER How to treat small coronary vessels with angioplasty Heart, March 1, 1998; 79(3): 215 - 216. [Full Text]

				D. S. Baim, D. E. Cutlip, S. K. Sharma, K. K. L. Ho, R. Fortuna, T. L. Schreiber, R. L. Feldman, J. Shani, C. Senerchia, Y. Zhang, et al. Final Results of the Balloon vs Optimal Atherectomy Trial (BOAT) Circulation, February 3, 1998; 97(4): 322 - 331. [Abstract] [Full Text] [PDF]

				C. A. Simonton, M. B. Leon, D. S. Baim, T. Hinohara, K. M. Kent, R. M. Bersin, B. H. Wilson, G. S. Mintz, P. J. Fitzgerald, P. G. Yock, et al. `Optimal' Directional Coronary Atherectomy : Final Results of the Optimal Atherectomy Restenosis Study (OARS) Circulation, February 3, 1998; 97(4): 332 - 339. [Abstract] [Full Text] [PDF]

				J Hancock, M R Thomas, S Holmberg, R J Wainwright, and D E Jewitt Randomised trial of elective stenting after successful percutaneous transluminal coronary angioplasty of occluded coronary arteries Heart, January 1, 1998; 79(1): 18 - 23. [Abstract] [Full Text] [PDF]

				A. Schomig, A. Kastrati, S. Elezi, H. Schuhlen, J. Dirschinger, F. Dannegger, M. Wilhelm, and K. Ulm Bimodal Distribution of Angiographic Measures of Restenosis Six Months After Coronary Stent Placement Circulation, December 2, 1997; 96(11): 3880 - 3887. [Abstract] [Full Text]

				J. P. Carrozza Jr and D. S. Baim Keeping the Open Artery Open : Is Stenting the Answer? Circulation, November 4, 1997; 96(9): 2762 - 2764. [Full Text]

				R. Albiero, T. Rau, M. Schluter, C. Di Mario, B. Reimers, D. G. Mathey, J. M. Tobis, J. Schofer, and A. Colombo Comparison of Immediate and Intermediate-Term Results of Intravascular Ultrasound Versus Angiography-Guided Palmaz-Schatz Stent Implantation in Matched Lesions Circulation, November 4, 1997; 96(9): 2997 - 3005. [Abstract] [Full Text]

				M. R. Ward, A. Agrotis, P. Kanellakis, R. Dilley, G. Jennings, and A. Bobik Inhibition of Protein Tyrosine Kinases Attenuates Increases in Expression of Transforming Growth Factor-ß Isoforms and Their Receptors Following Arterial Injury Arterioscler Thromb Vasc Biol, November 1, 1997; 17(11): 2461 - 2470. [Abstract] [Full Text]

				A. G. Adelman, F. Versaci, A. Gaspardone, and P. A. Gioffre A Comparison of Coronary-Artery Stenting with Angioplasty N. Engl. J. Med., July 24, 1997; 337(4): 277 - 278. [Full Text]

				P. S. Teirstein, V. Massullo, S. Jani, J. J. Popma, G. S. Mintz, R. J. Russo, R. A. Schatz, E. M. Guarneri, S. Steuterman, N. B. Morris, et al. Catheter-Based Radiotherapy to Inhibit Restenosis after Coronary Stenting N. Engl. J. Med., June 12, 1997; 336(24): 1697 - 1703. [Abstract] [Full Text] [PDF]

				D. P. Faxon Identifying the Predictors of Restenosis: Do We Need New Glasses? Circulation, May 6, 1997; 95(9): 2244 - 2246. [Full Text]

				G. W. Stone, J. M. Hodgson, F. G. St Goar, A. Frey, H. Mudra, H. Sheehan, and T. J. Linnemeier Improved Procedural Results of Coronary Angioplasty With Intravascular Ultrasound–Guided Balloon Sizing : The CLOUT Pilot Trial Circulation, April 15, 1997; 95(8): 2044 - 2052. [Abstract] [Full Text]

				P. Teirstein ß-Radiation to Reduce Restenosis: Too Little, Too Soon? Circulation, March 4, 1997; 95(5): 1095 - 1097. [Full Text]

				W. D. Coats, P. Whittaker, D. T. Cheung, J. W. Currier, B. Han, and D. P. Faxon Collagen Content Is Significantly Lower in Restenotic Versus Nonrestenotic Vessels After Balloon Angioplasty in the Atherosclerotic Rabbit Model Circulation, March 4, 1997; 95(5): 1293 - 1300. [Abstract] [Full Text]

				D. I. Simon, H. Xu, S. Ortlepp, C. Rogers, and N. K. Rao 7E3 Monoclonal Antibody Directed Against the Platelet Glycoprotein IIb/IIIa Cross-reacts With the Leukocyte Integrin Mac-1 and Blocks Adhesion to Fibrinogen and ICAM-1 Arterioscler Thromb Vasc Biol, March 1, 1997; 17(3): 528 - 535. [Abstract] [Full Text]

				F. Crawley, A. Clifton, H. Markus, and M. M. Brown Delayed Improvement in Carotid Artery Diameter After Carotid Angioplasty Stroke, March 1, 1997; 28(3): 574 - 579. [Abstract] [Full Text]

				H. Mudra, E. Regar, V. Klauss, F. Werner, K.-H. Henneke, E. Sbarouni, and K. Theisen Serial Follow-up After Optimized Ultrasound-Guided Deployment of Palmaz-Schatz Stents: In-Stent Neointimal Proliferation Without Significant Reference Segment Response Circulation, January 21, 1997; 95(2): 363 - 370. [Abstract] [Full Text]

				J.-M. Lablanche, G. Grollier, J.-R. Lusson, J.-P. Bassand, G. Drobinski, B. Bertrand, S. Battaglia, B. Desveaux, Y. Juilliere, J.-M. Juliard, et al. Effect of the Direct Nitric Oxide Donors Linsidomine and Molsidomine on Angiographic Restenosis After Coronary Balloon Angioplasty: The ACCORD Study Circulation, January 7, 1997; 95(1): 83 - 89. [Abstract] [Full Text]

				J. A. Bittl Advances in Coronary Angioplasty N. Engl. J. Med., October 24, 1996; 335(17): 1290 - 1302. [Full Text] [PDF]

				E. R. Edelman and C. Rogers Hoop Dreams: Stents Without Restenosis Circulation, September 15, 1996; 94(6): 1199 - 1202. [Full Text]

				R. Hoffmann, G. S. Mintz, G. R. Dussaillant, J. J. Popma, A. D. Pichard, L. F. Satler, K. M. Kent, J. Griffin, and M. B. Leon Patterns and Mechanisms of In-Stent Restenosis: A Serial Intravascular Ultrasound Study Circulation, September 15, 1996; 94(6): 1247 - 1254. [Abstract] [Full Text]