Impact of Plaque Calcification and Stent Oversizing on Clinical Outcomes of Atherosclerotic Femoropopliteal Arterial Occlusive Disease Following Stent Angioplasty

Abstract

WHAT THIS PAPER ADDS Plaque calcification and stent oversizing have been confirmed as two key factors for in stent restenosis in atherosclerotic peripheral artery occlusive disease. An effective plaque scoring system and specific stent oversizing standard have been well established in the coronary artery. However, there are still no similar assessment methods for the femoropopliteal artery. In this study, automatic computer software was used to analyse the pre-operative computed tomography angiography (CTA) images of patients receiving femoropopliteal artery stenting for atherosclerotic occlusive disease. Plaque calcification and stent oversizing were assessed by several quantitative parameters. Stent oversizing and plaque calcification were linked with adverse clinical outcomes. The results suggest potential cut off values of plaque calcification and stent oversizing, which may be useful for clinical intervention, and also imply the feasibility of quantitatively assessing plaques in the femoropopliteal artery on pre-operative CTA. Objective: Plaque calcification and stent oversizing are two key factors contributing to in stent restenosis (ISR) following femoropopliteal stent angioplasty. This study aimed to explore a pre-operative quantitative assessment method of plaque calcification and rational parameters of stent oversizing in the femoropopliteal artery. Methods: A total of 115 patients with atherosclerotic femoropopliteal arterial occlusive disease treated from January 2013 to January 2016 were included retrospectively. Computed tomography angiography (CTA) imaging was performed to analyse calcified plaque parameters (calcified plaque volume [CV], standard CV [SCV], burden of calcified plaque) and stent oversizing parameters at different vessel segments (distal oversizing, maximum oversizing, plaque oversizing). Optimal cut offs for the six parameters were determined by the maximum Youden's index. The relationship between calcified plaque, stent oversizing, and clinical outcomes were assessed by correlation analysis and multivariable Cox regression models. Results: The one year primary patency rate was 77.4%; the rates of ISR, major amputation, target lesion revascularisation, and mortality were 40.9%, 8.7%, 17.4%, and 12.2%, respectively. For all six parameters, patients with values greater than the cut offs had a significantly higher incidence of ISR than those with values below the cut offs. ISR was positively correlated with all six calcification and oversizing parameters. Amputation and mortality were positively correlated with calcification parameters. Multivariable Cox regression analysis demonstrated that all six parameters were independent risk factors for ISR. All calcification parameters were identified as independent risk factors for amputation, while only CV and SCV were independent risk factors for mortality. Conclusion: Calcified plaque in the femoropopliteal artery can be quantitatively analysed on pre-operative CTA images. High calcified plaque burden and excessive stent oversizing were ass...

Oversizing of Self-Expanding Nitinol Vascular Stents – A Biomechanical Investigation in the Superficial Femoral Artery

“…This pathological response was believed to be due to the greater chronic outward force exerted by the stent on the wall in case of severe oversizing. Similar behaviour was observed in humans by He et al (2019) who analysed computer tomography (CT) angiography from patients affected with atherosclerotic femoropopliteal arterial occlusive disease, and demonstrated a positive correlation between severe oversizing (40% oversizing rate evaluated at the narrowest cross-sectional level of target lesion) and the incidence of ISR. Timmins et al (2011) combined in vivo analysis with computational methods to prove a strong correlation between the stress induced in the artery wall and the pathobiological response, which could likely culminate in neointimal thickening.…”

“…On the other hand, stent undersizing could lead to incomplete strut-to-artery apposition, which is recognized as a cause of stent thrombosis (Cook et al, 2012) and, in extreme cases, stent migration following implantation (Zhao et al, 2009). While it has been reported that incorrect sizing likely contributes to a proportion of the adverse clinical outcomes (Attizzani et al, 2014), a set of objective criteria to select the most appropriate stent diameter in peripheral settings have not yet been established (He et al, 2019).…”

“…Experimental studies on animal and human models have investigated the effects of oversizing ratio OS on clinical outcomes. The OS value, which represents the ratio between the nominal stent diameter and lumen diameter at the target lesion site, typically ranges from 1 to 2 (Zhao et al, 2009;He et al, 2019;Cho et al, 2014). Zhao et al (2009) implanted self-expanding stents in iliofemoral arteries of swine animal models and observed a marked lumen narrowing, stenosis and intima formation in presence of severe oversizing, defined as a stent-to-artery ratio above 1.4.…”

Selenium-Containing Protein From Selenium-Enriched Spirulina platensis Attenuates High Glucose-Induced Calcification of MOVAS Cells by Inhibiting ROS-Mediated DNA Damage and Regulating MAPK and PI3K/AKT Pathways

“…VC may cause arterial stiffness, luminal stenosis, and plaque instability ( Wu et al, 2016 ), which was an independent risk factor for morbidity and mortality of cardiovascular and cerebrovascular diseases (CCD) ( Bugnicourt et al, 2011 ; Leon and Maddox, 2015 ). VC could also limit complete expansion of a stent or balloon during interventional therapy ( He et al, 2019 ). VC was also associated with poor prognosis after revascularization ( Lee et al, 2015 ).…”

One Year on: Test Your Knowledge From August 2019

“…According to the findings of a study, which of the following parameters are most closely associated with in-stent restenosis following femoropopliteal stenting? 4 A. A.…”