Analysis of macrophage accumulation using optical coherence tomography one year after sirolimus, paclitaxel and zotarolimus-eluting stent

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1 Analysis of macrophage accumulation using optical coherence tomography one year after sirolimus, paclitaxel and zotarolimus-eluting stent implantation.

2 Department of Cardiology, Ehime Prefectural Imabari Hospital Hideo Kawakami MD, Akira Oshita MD, Tamami Kono MD, Yuji Matsumoto MD, Hiroshi Matsuoka MD

3 Background Drug-eluting stent (DES) reduced the incidence of instent restenosis below 10%. However, a newly life threaten complication has been arisen, late and very late stent thrombosis (LST and VLST). Several mechanisms were thought to be causes of (V)LST. Plaque inflammation appears to be one of the causes of (V)LST. Recent intravascular imaging technique, optical coherence tomography (OCT) can detect macrophages accumulation, which play a important role of vascular inflammation.

4 Representative case of inflammatory neointima after sirolimus-eluting stent implantation detected by angioscopy Before PCI Immediately after PCI 400 days after PCI We could observe severe stenosis at proximal left descending artery (black arrow in A). Sirolimus-eluting stent was implanted and 400 days after PCI, there was no instent restenosis. The points designated by black arrowheads with number in B and C corresponds to images in next panel. Kawakami H, et al. J Cardiol 2009; 54:

5 CAS images immediately after PCI. CAS images 400 days after PCI. CAS images immediately after PCI. The plaque color of the distal to middle portion of the sirolimus-eluting stent were white (1,2), proximal portion was yellow (3) and proximal edge was white with red thrombus (black arrow in 4). CAS images 400 days after PCI. We could clearly observe that neointima cover the stent struts. Stent struts were slightly visible under the neointima (black arrows in 5, 6). All part of the neointima response to sirolimus-eluting stent was yellow. CAS; Coronary Angioscopy

6 Macrophage imaging by OCT This figure shows macrophage imaging by OCT and histology. Macrophage accumulation detected by raw OCT images were in accordance with the histology for a CD68 immunoperoxidase. Tearney GJ,et al. Circulation. 2003;107: This figure shows representative OCT images. Macrophage accumulate along with thin fibrous cap with high signal intensity. Macrophage accumulation is one of the marker of plaque vulnerability. OCT imaging terms, Akasaka T, Suzuki T 2009, Printed in Japan

7 Aim The aim of this study was to detect macrophages accumulation in the newly formed neointima response to DES using OCT.

8 Study subjects No. of cases No. of lesions Gender (M:F) Mean age (y.o., mean±sd) Mean follow up days (mean±sd) Clinical diagnosis (EAP/OMI/ACS) Diseased vessels (LAD/LCX/RCA) Observed DES (PES/SES/ZES=19/10/9) :18 71±5 366±105 23/3/5 21/4/13 19/10/9 This study was consisted of 31 patients, 38 lesions. Thirteen males, eighteen females, mean age was 71 years old. Mean follow up days was about 1 year after stent implantation. 23 patients were suffered from effort angina and 3 patients had old myocardial infarction and 5 patients were admitted by ACS. Diseased vessels we examine were 21 LADs, 4 LCXs and 13 RCAs. 19 paclitaxel-eluting stent (PES), 10 sirolimus-eluting stent (SES) and 9 zotarolimus-eluting stent (ZES) were observed.

9 OCT system (LightLab) ① ② ③ ④ ⑤ ⑥ This panel shows OCT system and procedure. ①A guide wire is advanced across the intended imaging area. ②The Helios Occlusion balloon catheter is advanced over the wire to the site of the lesion. ③The wire is removed and the ImageWire catheter is advanced beyond the distal margin of the imaging area. ④The balloon catheter is withdrawn and inflated. ⑤Flush is performed and an automatic pullback is initiated. The optical lens travels back through the target area and acquires the image.

10 Definition of macrophage accumulation by OCT Macrophage accumulation was defined as follows, high intensity signal band underlying low signal area or high intensity signal spot with low intensity line. A Superficial type B Deep type C A, B: These two figures show representative images of superficial macrophage accumulation. Superficial high intensity signal band underlying low signal area. C: This figure shows representative image of deep spotty macrophage accumulation.

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12 Case 1; EAP (# 7 75%, de novo lesion, SES 3.5x18mm) Before PCI Immediately after PCI 677 days after PCI A B C a b c This panel shows CAGs before PCI (A), immediately after PCI (B) and 677 days after PCI (C). This patient implanted SES at #7, de novo lesion where white arrows designate. There was no in-stent restenosis at chronic phase. The points of a,b,c designated in C corresponds to images in next panel. SES: sirolimus-eluting stent

13 a b c OCT CAS This panel shows intravascular imagings at SES implanted site in chronic phase. White curved lines depicted in upper panel shows macrophage accumulation. Angioscopic images, correspond to each OCT image, show yellow neointima, which means inflammatory response after SES implantation.

14 A Case 2; EAP (# 1 99%, de novo lesion, PES 3.5x32mm) Before PCI Immediately after PCI B This panel shows CAGs. This patient implanted PES at #1~2, de novo CTO lesion where white arrows designated (B). Proximal edge restenosis occurred (C) and implanted one more PES (D) and no ISR at chronic phase (E). The points of a,b,c designated in E corresponds to images in next panel. # 1 90%(edge restenosis) 350 days after PCI PES 3.5x8mm 966 days after PCI C D E a b c

15 a b c OCT CAS This panel shows intravascular imagings at PES implanted site. White curved lines depicted in upper panel, a, b and white arrow in c show macrophage accumulation. Angioscopic images, correspond to each OCT image, show yellow neointima (b, c) and yellow neointima with red thrombus (a), which means inflammatory response after PES implantation.

16 Results Frequency of macrophage accumulation in neointima Site of macrophage accumulation in neointima Macrophage(+) 39% (n=15) Deep type 40% (n=6) Superficial type 60% (n=9) Macrophage accumulation was observed 39% (n=15) of all DES. Nine of them were superficial site and six of them were deep site in the neointima.

17 Frequency of macrophage accumulation and accumulation site of each DES 70% 26% 33% This panel shows macrophage accumulation of each DES. 70% (n=7) of SES, 26% (n=5) of PES, 33% (n=3) of ZES had macrophage accumulation in intima. Site of macrophage accumulation in SES was almost superficial site, on the other hand, macrophage accumulation in deep site was more frequent in PES and ZES.

18 Conclusion OCT has a feasibility to detect macrophage accumulation in intima response to DES implantation. Declaration of interest There is no conflicts of interest regarding this poster presentation.