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J Am Coll Cardiol, 2006; 47:1363-1368, doi:10.1016/j.jacc.2005.11.055 (Published online 14 March 2006).
© 2006 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: ATHEROSCLEROSIS

Remodeling Index Compared to Actual Vascular Remodeling in Atherosclerotic Left Main Coronary Arteries as Assessed With Long-Term (≥12 Months) Serial Intravascular Ultrasound

Clemens von Birgelen, MD, PhD*,*, Marc Hartmann, MD*, Gary S. Mintz, MD, FACC{ddagger}, Dirk Böse, MD{dagger}, Holger Eggebrecht, MD{dagger}, Till Neumann, MD{dagger}, Mario Gössl, MD{dagger}, Heinrich Wieneke, MD{dagger}, Axel Schmermund, MD{dagger}, Martin G. Stoel, MD*, Patrick M.J. Verhorst, MD, PhD* and Raimund Erbel, MD, FACC{dagger}

* Medisch Spectrum Twente, Department of Cardiology, Enschede, the Netherlands
{dagger} Essen University, Department of Cardiology, Essen, Germany
{ddagger} Cardiovascular Research Foundation, New York, New York.

Manuscript received July 28, 2005; revised manuscript received October 26, 2005, accepted November 8, 2005.

* Reprint requests and correspondence: Dr. Clemens von Birgelen, Medisch Spectrum Twente, Thoraxcenter Twente, Cardiology Department, Haaksbergerstraat 55, 7513 ER Enschede, the Netherlands. (Email: von.birgelen{at}12move.nl).


   Abstract
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 Abstract
Methods
 Results
 Discussion
 References
 
OBJECTIVES: We present the remodeling index (RI) versus serial intravascular ultrasound (IVUS) data.

BACKGROUND: The RI, derived by comparing lesion external elastic membrane (EEM) cross-sectional area versus the reference at one time point, is used in various IVUS studies as a substitute of true remodeling (change in EEM over time), assuming that it represents true remodeling.

METHODS: We studied 46 non-stenotic left main arteries using serial IVUS (follow-up 18 ± 8 months). Plaques were divided into subgroups according to the follow-up RI: follow-up RI >1 (n = 27) versus follow-up RI ≤1 (n = 19).

RESULTS: Lesions with a follow-up RI >1 had an increase in lumen despite an increase in plaque because of an increase in EEM. Conversely, lesions with a follow-up RI ≤1 had a reduction in lumen as a result of both a plaque increase and EEM decrease. Overall, the follow-up RI correlated directly with changes in lesion site EEM (baseline-to-follow-up). Although there was no correlation between the follow-up RI and changes in reference EEM area, changes in reference EEM area did correlate directly with changes in lesion EEM area. In nearly 90% of lesions with a follow-up RI >1, there was a previously documented increase in EEM area. Using multivariate linear regression analysis, the follow-up RI was dependent on the baseline RI, the increase in lesion EEM area, and the decrease in reference EEM area. The follow-up RI was not dependent on changes in lesion plaque area.

CONCLUSIONS: The vast majority of left main lesions with a remodeling index >1 had evidence of a previous increase in lesion-site EEM area.

Abbreviations and Acronyms
  CSA = cross-sectional area
  EEM = external elastic membrane
  IVUS = intravascular ultrasound
  P&M = plaque and media
  RI = remodeling index

Both histopathologic (1–3) and intravascular ultrasound (IVUS) analyses (3–12) have described positive and negative remodeling of atherosclerotic lesions, typically by comparing absolute lesion-site external elastic membrane (EEM) measurements to the reference segments at a single point in time. For example, a remodeling index (RI) can be derived as lesion-site EEM cross-sectional area (CSA) divided by a pre-defined reference vessel area; RI >1 is considered evidence for positive remodeling, whereas RI ≤1 suggests intermediate or negative remodeling. However, for many reasons (such as single time-point observation as well as reference segment selection, tapering, plaque burden, and remodeling), these indexes are acknowledged to be only indirect evidence of remodeling (13,14). Direct evidence of remodeling requires serial EEM measurements obtained at two (or more) time points (15–19).

In the present serial IVUS study in non-stenotic left main coronary lesions, we assessed whether the more commonly used indirect assessment of remodeling (i.e., the RI) reflects true vascular remodeling (i.e., changes in lesion-site EEM CSA). Therefore, we compared the RI at follow-up with the preceding changes in vessel dimensions.


   Methods
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Results
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Study population.   We analyzed serial IVUS data of 46 patients who had hemodynamically non-significant de novo left main atherosclerotic lesions and reliable reference segments; these patients were from a population of 60 lesions that has previously been reported (18,19). Fourteen left main lesions were excluded because there was a lack of a well-defined reference (14).

All patients met the following criteria: 1) serial high-quality IVUS imaging of the entire left main stem ≥12 months apart; 2) calcifications that did not limit the quantitative assessment of vessel area (shadowing ≤75° of the adventitial circumference by individual calcific deposits); 3) non-ostial target site location; 4) angiographic lumen diameter stenosis <30% ("worst view" visual assessment); 5) no intervention in the very proximal left anterior descending or circumflex coronary artery segments because these interventions could have affected the left main artery; and 6) well-defined lesion and reference image slices. Patients were examined in the Essen University Cardiac Catheterization Laboratory with a follow-up of 17.7 ± 8.1 months (median 15 months, range 12 to 49 months). As previously reported, this represents a consecutive series of patients who underwent initial IVUS examination during coronary intervention and then returned after ≥1 year for repeat intervention during which another IVUS study was performed (18). The IVUS study was approved by the local council on human research. All patients signed a written informed consent form as approved by the local medical ethics committee.

Demographics, medications, and lipid status.   Demographics including cardiovascular risk factors, medications, and the lipid status were prospectively recorded in our laboratory including diabetes mellitus and hypertension (both medication-dependent only); hypercholesterolemia (medication-dependent, total serum cholesterol >200 mg/dl, or low-density lipoprotein cholesterol >160 mg/dl); history of smoking; and family history of coronary artery disease. Data of laboratory tests were means of the baseline and follow-up values. Medications were recorded only if drugs were taken for >50% of the follow-up interval (e.g., clopidogrel for four weeks was not tabulated). Plasma concentrations of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides were measured by standard enzymatic methods.

IVUS imaging.   Intravascular ultrasound was performed as previously described (18). In brief, IVUS studies were performed during percutaneous coronary interventions of mid- or distal left anterior or left circumflex arteries after intracoronary injections of 200 µg nitroglycerin. Two commercial systems were used: a mechanical sector scanner (Boston Scientific Corporation, San Jose, California) incorporating a 30-MHz single-element beveled transducer or a solid-state device (Endosonics, Rancho Cordova, California). Importantly, at Essen University, if a patient undergoes imaging with one IVUS system during an index procedure, the same IVUS system is used at follow-up. Slow continuous pullbacks of the IVUS transducer were started as distal as possible in one of the left coronary arteries and were generally performed using a motorized pullback device (at 0.5 mm/s); IVUS images of the entire pullback were recorded on 0.5-inch high-resolution s-VHS tape for off-line analysis. In addition, a dedicated image-in-image system (Echo-Map, Siemens, Erlangen, Germany) (20) was used to record the "angiographic" position of the IVUS probe together with the corresponding IVUS image—especially at sites of characteristic landmarks (i.e., calcifications or unusual plaque shapes) and/or the target site. Follow-up IVUS studies were performed (using the same IVUS system as initially) during repeat coronary interventions or during IVUS examinations of ambiguous left coronary lesions or (clinically driven) follow-up catheterizations.

Quantitative IVUS analysis.   The target lesion site image slice was the slice with the smallest lumen CSA (18). If there were several slices with equal lumen size, the one with the largest EEM and plaque and media (P&M = EEM – lumen) CSA was analyzed (6,14). A left main stem reference image slice was selected as the most normal-looking cross section (largest lumen with smallest P&M) distal or proximal to the target lesion. Exact matching of the initial and follow-up IVUS studies was ensured using side-by-side comparison of the serial IVUS video sequences along with information of the pullback speed (18); the operators’ recorded comments (on videotape); and characteristic calcifications, vascular and perivascular landmarks, and plaque shapes. If required, the X-ray sequences of the dedicated image-in-image system (Echo-Map) were revisited to optimize matching (18,20).

The lumen CSA was measured by tracing the leading edge of the intima. The EEM CSA was measured by tracing the leading edge of the adventitia. As in many previous IVUS studies, P&M was used as a measure of atherosclerotic plaque because IVUS cannot measure media thickness accurately. Lumen and plaque eccentricity ([maximum lumen/plaque diameter minus minimum lumen/plaque diameter] divided by maximum lumen/plaque diameter) was calculated. In our laboratory, the intraclass correlation coefficient is 0.99 for repeated measurements of EEM, 0.96 for lumen, and 0.99 for P&M CSA.

We calculated the changes between ({Delta}) the initial and follow-up IVUS data. To compensate for the variation in follow-up interval and to obtain comparable data, measurements were normalized for the length of the follow-up period and annual changes (i.e., changes per year) were reported and compared.

Direct (serial IVUS) measurement of arterial remodeling and RI.   The change in lesion-site EEM CSA was the direct measure of arterial remodeling (i.e., serial arterial remodeling or "remodeling behavior"). The RI was calculated at follow-up as lesion site divided by reference EEM CSA (13,14) and used to classify lesions into positive remodeling (RI >1) and intermediate/negative remodeling (RI ≤1).

Statistics.   Analyses were performed with SPSS 10.0.7 (Microsoft, Redmond, Washington) and MedCalc (version 4.16, Mariakerke, Belgium) software packages for Windows. Dichotomous data are presented as frequencies and compared using chi-square statistics; Fisher exact test was applied if at least one expected frequency was ≤5. Quantitative data are presented as mean values ± 1 SD and compared using Student t test and linear regression analysis. A value of p < 0.05 was considered significant.


   Results
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Discussion
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Study population.   Plaques were divided into two groups according to the follow-up RI: follow-up RI >1 (n = 27) versus RI ≤1 (n = 19). The actual RI values were 1.15 ± 0.16 and 0.89 ± 0.09, respectively (p < 0.0001). There was no difference in demographics, medication, and lipid status between the two groups (Table 1).


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  		Table 1. Patient Demographics, Medication, and Lipid Status
 
Follow-up IVUS remodeling.   In lesions with a follow-up RI >1, baseline reference EEM and lumen CSA were smaller and baseline RI was larger compared to lesions with a follow-up RI ≤1 (Table 2). The other baseline IVUS measurements—reference P&M CSA and lesion EEM, lumen, and P&M CSA as well as lesion plaque burden—were similar between the two groups.


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  		Table 2. Comparison of the Baseline IVUS Data According to Follow-Up Remodeling Index
 
We then analyzed the baseline-to-follow-up changes in IVUS measurements in patients with follow-up left main stem RI >1 versus follow-up RI ≤1 (Table 3). Changes in reference segment EEM, lumen, and P&M CSA measurements were similar between the two groups. The two groups had similar increases in lesion P&M CSA from baseline to follow-up. However, lesions with a follow-up RI >1 had an increase in minimum lumen CSA despite this increase in P&M CSA; this was the result of an increase in lesion EEM CSA. Conversely, on average, lesions with a follow-up RI ≤1 had a reduction in minimum lumen CSA as a result of both, P&M CSA increase and EEM CSA decrease.


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  		Table 3. Comparison of the Serial IVUS Data According to Follow-Up Remodeling Index
 
Overall, the follow-up RI correlated directly with {Delta}lesion-site EEM CSA (baseline-to-follow-up) (Fig. 1); of note, there was a substantial amount of patient-to-patient variation. In addition, there was no correlation between {Delta}reference EEM CSA and the follow-up RI (y = –0.01x + 1.05, r = 0.16, p = 0.15; graph not shown), whereas {Delta}reference EEM CSA did correlate directly with {Delta}lesion EEM CSA (y = 0.41x + 0.82, r = 0.53, p < 0.001; graph not shown).


Figure 1
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  		Figure 1 Relation between annual changes in vessel dimensions at lesion site versus the remodeling index at follow-up. Serial (baseline-to-follow-up) changes in external elastic membrane (EEM) cross-sectional area (CSA) correlated with the remodeling index at follow-up.

 
Using multivariate linear regression analysis, the follow-up RI was dependent on the baseline RI, the increase in lesion-site EEM CSA, and the decrease in reference EEM CSA. The follow-up RI was not dependent on changes in lesion-site P&M CSA.

Follow-up versus baseline RI.   There was a significant linear relationship between the follow-up RI and the baseline RI (Fig. 2). In 74% of lesions, the classification of remodeling as positive or intermediate/negative was similar at baseline and follow-up (Table 4).


Figure 2
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  		Figure 2 Linear relation between the remodeling index at follow-up versus the remodeling index at baseline.

 

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  		Table 4. Comparison of Positive Versus Intermediate/Negative Remodeling Classification at Baseline and Follow-Up
 

   Discussion
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Positive (or outward) remodeling has been postulated to explain the finding of atherosclerosis that does not encroach on the arterial lumen. Remodeling of atherosclerotic human coronary arteries was described first by Glagov et al. (1) (primarily in non-stenotic reference segments from autopsied hearts) by correlating EEM CSA with plaque CSA and plaque burden. The observations by Glagov et al. (1) were confirmed in vivo using IVUS (3,4,13). Since then, lesion remodeling has been most often studied by comparing the lesion to proximal and/or distal reference segments at a single point in time to generate an RI, even though these reference segments have also remodeled (13). Lesions are classified as positive versus intermediate and negative remodeling based on this comparison (13,14). Although there are many theoretical limitations to this approach (13), the results of our current serial IVUS study show that the RI is a relatively good substitute of true vascular remodeling.

When the baseline-to-follow-up change in EEM CSA was compared to the follow-up RI, lesions with a follow-up RI >1 had a previously documented increase in EEM in nearly 90%. The independent predictors of the follow-up RI were the baseline RI, the increase in lesion EEM CSA, and the decrease in reference EEM CSA. Our study demonstrates that the classification of a lesion as positive versus intermediate/negative remodeling tends to remain relatively constant over time. We found a significant linear relationship between the follow-up RI versus the baseline RI, and in almost 75% of lesions, the classification was similar at baseline and after 18 months of follow-up. In particular, positively remodeled lesions continued to positively remodel.

We found a significant correlation between changes in lesion EEM CSA (serial remodeling) and the follow-up RI. However, there was a substantial patient-to-patient variation (e.g., the RI varied from approximately 0.7 to 1.5 when in fact there was no serial remodeling) (Fig. 1). Thus, the RI may be a very good correlate of true remodeling for a population rather than for an individual lesion.

In addition, our data showed no difference in baseline plaque burden between lesions with positive versus negative RI, thereby questioning the concept that remodeling occurs until approximately 40% of the artery is occupied by plaque (1).

IVUS insights into remodeling from previous serial studies.   Few serial IVUS studies in native coronary arteries (like the present study) have been reported. Such studies permit an assessment of remodeling independent of reference segment changes. Shiran et al. (15) studied 31 left main stems to demonstrate that lumen changes during six months follow-up resulted primarily from EEM changes (i.e., remodeling). Although the assessment of arterial remodeling was not the main purpose of the pharmacological intervention studies by Takagi et al. (16) and Schartl et al. (17), the presence of positive remodeling was clearly demonstrated.

Why study arterial remodeling?.   Cumulative evidence from various studies suggests that positively remodeled lesions are more biologically active than intermediate or negatively remodeled lesions and that they occur in patients who are more prone to develop additional unstable lesions or other forms of clinical instability (21,22). For instance, de novo coronary lesions in patients with acute coronary syndromes more often have positive remodeling characteristics compared with either chronic stable angina lesions or to control plaques elsewhere in the coronary tree (9,10,12,23). In addition, positive remodeling was found to be strongly associated with single and multiple plaque ruptures and thrombus formation in such patients (11,24–26). In the context of percutaneous coronary interventions, positive remodeling has been shown to be a predictor of: 1) post-interventional creatinine kinase-MB elevation (27); 2) no reflow after primary infarct angioplasty (28); 3) recurrent ischemia within one month after thrombolysis for acute myocardial infarction (29); 4) target lesion revascularization after non-stent interventions (30); 5) major adverse coronary events in patients with unstable angina undergoing percutaneous revascularization (31); 6) target vessel revascularization and intimal hyperplasia after bare metal stenting (32,33); 7) intimal hyperplasia after implantation of drug-eluting stents (34); and 8) in-hospital complications, major adverse coronary events, restenosis, and new lesion formation in patients with stable angina (35).

Study limitations.   By most standards, this was a large serial IVUS study; however, all long-term serial IVUS studies are limited to a relatively small number of patients. We only studied left main disease as representative of non-intervened coronary segments; therefore, our findings may not be applicable to all (stenotic and non-stenotic) coronary segments. We only included patients who underwent non-left main intervention and who were admitted for repeat cardiac catheterization ≥12 months later; thus, the findings of the current study may not be applicable to the general population (36). We used two IVUS systems; although this approach may have shortcomings, every effort was taken to obtain the most reliable data possible as previously discussed (18). Three-dimensional (electrocardiogram-gated) IVUS analyses (37) may be superior for the assessment of atherosclerotic coronary arteries compared to the two-dimensional analysis used in the current study. All patients were Caucasian, and most were men. We only used one classification of remodeling; there are others that have been reported. Of the 60 patients who have been reported previously, only 46 patients could be included in this analysis because of a lack of a well-defined reference segment in the other 14 patients. Our data did not permit the comparison of different definitions of the RI (38); therefore, our findings may be limited to the definition used in the present study.

Conclusions.   The vast majority of lesions with positive remodeling classification (RI >1) had evidence of a previous increase in lesion-site EEM CSA.


   References
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 Abstract
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 Results
 Discussion
 References
 

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