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Gary S. Mintz, Why are we so concerned with acute incomplete stent apposition?, European Heart Journal - Cardiovascular Imaging, Volume 16, Issue 1, January 2015, Pages 110–111, https://doi.org/10.1093/ehjci/jeu199
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In their article, Shimamura et al. report that incomplete stent apposition (ISA) was observed in all 38 everolimus-eluting stents (EES) and all 39 sirolimus-eluting stents (SES) post-percutaneous coronary intervention (PCI) (measuring 315 ± 94 µm and 0.50 ± 0.24 mm2 in EES and 308 ± 119 µm and 0.95 ± 0.70 mm2 in SES), that it persisted in 26% of EES and 38% of SES at 8–12 months although the size of the ISA significantly decreased during follow-up in both groups (to 110 ± 165 µm and 0.17 ± 0.27 mm2 in EES and 143 ± 175 µm and 0.41 ± 0.66 mm2 in SES), and that the best post-stenting optical coherence tomographic (OCT)-measured ISA distance that predicted late-persistent ISA was >355 µm in EES and >285 µm in SES.1 The authors concluded: ‘OCT can predict late-persistent ISA after DES implantation and provide useful information to optimize PCI’.
Why are we so concerned with acute ISA? Despite the lack of supporting evidence, the most recent Cardiac Catheterization and Interventional Cardiology Self-Assessment Program (CathSAP) stated, ‘stent apposition may be the most important determinant of freedom from subacute stent thrombosis with DES’.2 To the contrary, the predictors of early ST that have been identified with intravascular imaging are primarily stent underexpansion and secondarily inflow/outflow problems such as a larger plaque burden, a small lumen area, and/or a large dissection at either stent edge.3 Depending on the sensitivity of the methodology used, ISA after DES implantation is observed in up to 40% by IVUS in patients undergoing primary PCI4 and 60–100% in stable patients by OCT.1,5 Given the nearly ubiquitous finding of acute ISA, it is not surprising that studies using IVUS2,6 or OCT5 have shown no relationship between acute ISA and early, late, or very late stent thrombosis after DES implantation.
