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Acute and chronic tissue response to coronary stent implantation: pathologic findings in human specimen

Peter H. Grewe, MD^*, Thomas Deneke, MD^*, Abderrahman Machraoui, MD^*, J.ürgen Barmeyer, MD^* and Klaus-Michael Müller, MD

^* Department of Cardiology and Angiology, University Hospital "Bergmannsheil," Bochum, Germany
Institute of Pathology, University Hospital "Bergmannsheil," Bochum, Germany

View larger version (106K): [in a new window]   Figure 1 A, Light microscopic specimen (subject no. 243/95). Histologic cross section of a stented coronary artery. Implantation pressures of 15 atm did not produce complete stent expansion. Subacute stent thrombosis after 12 days. Lumen obstructed by thrombotic material (th). Extensive calcification (ca) impeding complete homogeneous stent expansion. S = stent strut. (Magnification x11, reduced by 65%.) B, Gross specimen (subject no. 365/96). Longitudinally dissected coronary artery 11 days after stenting. The endoprosthesis is incompletely covered by a thin, membranous thrombus . In between stent filaments multiple intramural hematomas can be identified. (Magnification x7.) C, Light microscopic specimen (subject no. 122/95) of a histologic cross section of a coronary artery 28 days after stenting. Stent struts (S) show coating by neointima (n) with few cellular infiltrates. The borderline between neointima and arteriosclerotic plaque (p) is still visible. Lumen (l) filled with contrast medium after postmortem coronary angiography. m = media; a = adventitia. (Magnification x25, reduced by 65%.) D, Gross specimen (subject no. 291/96). Longitudinal section of a coronary artery six months after stent implantation. Stent struts (S) covered by gray neointima. Intercellular hemosiderin pigments as residuals of intramural bleedings (b) caused by the implantation trauma in the outer media. l = lumen. (Magnification x8.5, reduced by 65%.)

View larger version (124K): [in a new window]   Figure 2 A, Immunohistochemical staining (alpha-actin). Neointima 101 days after stenting (subject no. 324/97). Compact layer of alpha-actin testing positive cells (red) in the luminal zone of the intima. Loose infiltration with alpha-actin–positive cells of the intercellular matrix in the thicker, outer layer of the neointima. (Magnification x45, reduced by 65%.) B, Light microscopic specimen. Stent neointima after removal of the stent struts (s) (subject no. 174/97). Directly adjacent to the alloplastic stent filaments no alpha-actin–positive SMCs (red) can be detected. (Magnification x45, reduced by 65%.) C, Immunohistochemical staining after removal of stent struts (subject no. 38/95). Factor 8-negative cells form the borderline between the lumen (l) and neointima (n) 68 days after stenting. Endothelial cells of the hyperemic vasa vasorum (v) are tested factor 8–positive. Indentation of stent struts. (Magnification x35, reduced by 65%.) D, Immunohistochemical staining (factor 8-positive = red). Complete endothelialization of the neointima by mature endothelial cells 101 days after stenting (subject no. 324/97). Upper, lumen; lower, neointima (distal stent). (Magnification x75, reduced by 65%.)

View larger version (198K): [in a new window]   Figure 3 A, Immunohistochemical staining (CD3-positive = red). Neointima 96 days after stenting (subject no. 291/96). CD3-positive T lymphocytes aggregated around the stent struts. Impression of a removed stent filament in the lower right of the figure. Magnification: CD3-positive cells. s = stent strut. (Magnification x35, reduced by 65%.) B, Immunohistochemical staining (CD20-positive = red). Neointima 96 days after stenting (subject no. 291/96). No CD20-positive B lymphocytes in the stent neointima. s = stent strut. (Magnification x35, reduced by 65%.) C, Immunohistochemical staining (CD3-positive = red). Neointima 124 days after stenting. Diffuse infiltration by CD3-positive T lymphocytes in this phase of stent integration. s = stent strut. (Magnification x35, reduced by 65%.) D, Immunohistochemical staining (CD20-positive = red). Neointima 124 days after stenting (subject no. 291/96). No CD20-positive B lymphocytes in the stent neointima. s = stent strut. (Magnification x35, reduced by 65%.) E, Immunohistochemical staining (CD3-positive = red). No CD3-positive T lymphocytes in the vessel segment 2 cm proximal to the stent (subject no. 291/96). (Magnification x45, reduced by 65%.) F, Immunohistochemical staining (CD20-positive = red). No CD20-positive B lymphocytes in the vessel segment 2 cm proximal to the implanted stent (subject no. 291/96). (Magnification x45, reduced by 65%.)