Author + information
- Received May 8, 2013
- Revision received September 3, 2013
- Accepted September 4, 2013
- Published online November 1, 2013.
- Soo-Jin Kang, MD, PhD∗,
- Young-Rak Cho, MD†,
- Gyung-Min Park, MD∗,
- Jung-Min Ahn, MD∗,
- Seung-Bong Han, PhD‡,
- Jong-Young Lee, MD∗,
- Won-Jang Kim, MD∗,
- Duk-Woo Park, MD, PhD‡,
- Seung-Whan Lee, MD, PhD∗,
- Young-Hak Kim, MD, PhD∗,
- Cheol Whan Lee, MD, PhD∗,
- Seong-Wook Park, MD, PhD∗,
- Gary S. Mintz, MD§ and
- Seung-Jung Park, MD, PhD∗∗ ()
- ∗Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
- †Department of Cardiology, Dong-A University Hospital, Pusan, Korea
- ‡Department of Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
- §Cardiovascular Research Foundation, New York, New York
- ↵∗Reprint requests and correspondence:
Dr. Seung-Jung Park, Department of Cardiology, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736 South Korea.
Objectives The aim of this study was to assess the clinical and morphological predictors for functionally significant in-stent restenosis (ISR).
Background Although they have been studied de novo in native coronary artery lesions, the relationships between clinical and morphological characteristics and the hemodynamic significance of ISR are not well understood.
Methods In 175 patients with ISR of a single coronary artery (angiographic stenosis >50%), we compared quantitative coronary angiography and intravascular ultrasound (IVUS) with stress myocardial single-photon emission computed tomography (SPECT). A positive SPECT was a reversible perfusion defect in the territory of the ISR artery.
Results Overall, 103 (59%) patients had a positive SPECT. In-segment IVUS minimal lumen area (MLA) was significantly smaller in lesions with positive SPECT compared with negative SPECT (1.7 ± 0.5 mm2 vs. 2.4 ± 0.8 mm2, p < 0.001). Stent underexpansion (minimal stent area <5.0 mm2) was more common in the positive SPECT group than in the negative SPECT group (52% vs. 32%, p = 0.010). A positive SPECT was seen in 54% (65 of 121) of focal ISR lesions compared with 70% (38 of 54) of multifocal or diffuse ISR lesions as assessed by IVUS (p = 0.039). Independent determinants for a positive SPECT were diabetes (odds ratio [OR]: 2.41; 95% confidence interval [CI]: 1.02 to 5.68; p = 0.046), in-segment angiographic diameter stenosis (OR: 1.06; 95% CI: 1.03 to 1.09; p < 0.001), in-segment IVUS-MLA (OR: 0.30; 95% CI: 0.14 to 0.63; p = 0.001), stent underexpansion (minimal stent area <5.0 mm2), (OR: 2.91; 95% CI: 1.19 to 7.07; p = 0.019), proximal location of the IVUS-MLA (OR: 4.62; 95% CI: 1.75 to 12.18; p = 0.002), and a multifocal or diffuse ISR pattern (OR: 2.50; 95% CI: 0.99 to 6.28; p = 0.050). An in-segment angiographic diameter stenosis ≥69.5% (72% sensitivity, 74% specificity, area under the curve = 0.793) and an IVUS-MLA ≤1.9 mm2 (67% sensitivity, 75% specificity, area under the curve = 0.756) best predicted a positive SPECT; however, the overall diagnostic accuracies were only 73% and 70%, respectively.
Conclusions In lesions with ISR, neither angiography nor IVUS accurately predicted an abnormal SPECT.
This study was supported by a grant from the Korea Healthcare Technology Research and Development Project, Ministry of Health and Welfare (A120711), and CardioVascular Research Foundation, Seoul, South Korea. Dr. Mintz has received grant support from BostonScientific, Volcano, and InfraReDx; and is a consultant or speaker for BostonScientific, Volcano, St. Jude, and InfraReDx. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Stephen Nicholls, MBBS, PhD, served as Guest Editor for this article.
- Received May 8, 2013.
- Revision received September 3, 2013.
- Accepted September 4, 2013.
- American College of Cardiology Foundation