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      Impact of chronic outward force on arterial responses of proximal and distal of long superficial femoral artery stent

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          Abstract

          Background

          Self-expanding nitinol stent (SENS) implantation is commonly oversized in the superficial femoral artery (SFA), and leads to chronic outward force (COF) and in-stent restenosis (ISR). This study aimed to investigate the impact of COF of oversizing SENS on ISR of SFA.

          Methods

          In patients with implanted SENS in SFA, intimal hyperplasia especially between proximal segment and distal segment was evaluated by quantitative angiography, and the impact of COF on mid-term angiographic outcomes was investigated. In addition, porcine model with implanted SENS was used to evaluate the impact of COF on angiographic and histopathologic outcomes at 1 month. Excised stented arteries were evaluated by histopathologic analysis.

          Results

          We analyzed 65 SENS in 61 patients with follow-up angiography at 6 months to 1 year. The baseline diameter was 6.8 ± 0.71 mm and length were 97.0 ± 33.8 mm for the SENS. The ratio of the diameter of the stent to the reference vessel was 1.3 ± 0.24 at the proximal portion and 1.53 ± 0.27 at the distal portion ( P < 0.001). In the long SFA stent, stent-to-vessel ratio was significantly higher in the distal stent than in the proximal stent (1.3 ± 0.2 vs. 1.55 ± 0.25, P = 0.001). ISR incidence was higher at the distal stent (37.3% vs 52.6%, P = 0.029). All 11 pigs survived for 4 weeks after SENS implantation. The vessel diameter was 4.04 ± 0.40 mm (control group) vs 4.45 ± 0.63 mm (oversized group), and the implanted stent diameter was 5.27 ± 0.46 mm vs. 7.18 ± 0.4 mm ( P = 0.001). The stent-to-vessel diameter ratio was 1.31 ± 0.12 versus 1.63 ± 0.20 ( P < 0.001). After 4 weeks, restenosis % was 29.5 ± 12.9% versus 46.8 ± 21.5% ( P = 0.016). The neointimal area was 5.37 ± 1.15 mm 2 vs. 8.53 ± 5.18 mm 2 ( P = 0.05). The restenosis % was 39.34 ± 8.53% versus 63.97 ± 17.1% ( P = 0.001).

          Conclusions

          COF is an important cause of restenosis in the distal portion of the SFA stent. Optimal sizing of the SFA stent is important to reduce the incidence of restenosis. Therefore, COF was an important factor of restenosis following distal SFA stenting.

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          Most cited references25

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          Balloon angioplasty versus implantation of nitinol stents in the superficial femoral artery.

          Tobias P. Dick, Schila Sabeti, Martin Schillinger … (2006)
          Because stent implantation for disease of the superficial femoral artery has been associated with high rates of late clinical failure, percutaneous transluminal angioplasty is preferred for endovascular treatment, and stenting is recommended only in the event of suboptimal technical results. We evaluated whether primary implantation of a self-expanding nitinol (nickel-titanium) stent yielded anatomical and clinical benefits superior to those afforded by percutaneous transluminal angioplasty with optional secondary stenting. We randomly assigned 104 patients who had severe claudication or chronic limb ischemia due to stenosis or occlusion of the superficial femoral artery to undergo primary stent implantation (51 patients) or angioplasty (53 patients). Restenosis and clinical outcomes were assessed at 6 and 12 months. The mean (+/-SD) length of the treated segment was 132+/-71 mm in the stent group and 127+/-55 mm in the angioplasty group. Secondary stenting was performed in 17 of 53 patients (32 percent) in the angioplasty group, in most cases because of a suboptimal result after angioplasty. At 6 months, the rate of restenosis on angiography was 24 percent in the stent group and 43 percent in the angioplasty group (P=0.05); at 12 months the rates on duplex ultrasonography were 37 percent and 63 percent, respectively (P=0.01). Patients in the stent group were able to walk significantly farther on a treadmill at 6 and 12 months than those in the angioplasty group. In the intermediate term, treatment of superficial-femoral-artery disease by primary implantation of a self-expanding nitinol stent yielded results that were superior to those with the currently recommended approach of balloon angioplasty with optional secondary stenting. (ClinicalTrials.gov number, NCT00281060.). Copyright 2006 Massachusetts Medical Society.
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            Restenosis and the proportional neointimal response to coronary artery injury: results in a porcine model.

            Robert S Schwartz, Kenneth C Huber, Joseph G Murphy … (1992)
            Restenosis is a reparative response to arterial injury occurring with percutaneous coronary revascularization. However, the quantitative characteristics of the relation between vessel injury and the magnitude of restenotic response remain unknown. This study was thus performed to determine the relation between severity of vessel wall injury and the thickness of resulting neointimal proliferation in a porcine model of coronary restenosis. Twenty-six porcine coronary artery segments in 24 pigs were subjected to deep arterial injury with use of overexpanded, percutaneously delivered tantalum wire coils. The vessels were studied microscopically 4 weeks after coil implantation to measure the relation between the extent of injury and the resulting neointimal thickness. For each wire site, a histopathologic score proportional to injury depth and the neointimal thicknesses at that site were determined. Mean injury scores were compared with both mean neointimal thickness and planimetry-derived area percent lumen stenosis. The severity of vessel injury strongly correlated with neointimal thickness and percent diameter stenosis (p less than 0.001). Neointimal proliferation resulting from a given wire was related to injury severity in adjacent wires, suggesting an interaction among effects at injured sites. If the results in this model apply to human coronary arteries, restenosis may depend on the degree of vessel injury sustained during angioplasty.
            Article 0 comments Cited 116 times – based on 0 reviews     Review now
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              Nitinol stent implantation versus balloon angioplasty for lesions in the superficial femoral artery and proximal popliteal artery: twelve-month results from the RESILIENT randomized trial.

              Matthew Laird, Kunjan Dave, Alexandra Lansky … (2010)
              Controversy still exists regarding the best endovascular treatment strategy for patients with symptomatic disease of the superficial femoral artery. There are conflicting data regarding the benefits of superficial femoral artery stenting and the role of primary stenting compared with balloon angioplasty with provisional stent implantation. A total of 206 patients from 24 centers in the United States and Europe with obstructive lesions of the superficial femoral artery and proximal popliteal artery and intermittent claudication were randomized to implantation of nitinol stents or percutaneous transluminal angioplasty. The mean total lesion length was 71 mm for the stent group and 64 mm for the angioplasty group. Acute lesion success (<30%residual stenosis) was superior for the stent group compared with the angioplasty group (95.8% versus 83.9%; P<0.01). Twenty-nine (40.3%) patients in the angioplasty group underwent bailout stenting because of a suboptimal angiographic result or flow-limiting dissection. Bailout stenting was treated as a target lesion revascularization and loss of primary patency in the final analysis. At 12 months, freedom from target lesion revascularization was 87.3% for the stent group compared with 45.1% for the angioplasty group (P<0.0001). Duplex ultrasound-derived primary patency at 12 months was better for the stent group (81.3% versus 36.7%; P<0.0001). Through 12 months, fractures occurred in 3.1% of stents implanted. No stent fractures resulted in loss of patency or target lesion revascularization. In this multicenter trial, primary implantation of a self-expanding nitinol stent for moderate-length lesions in the superficial femoral artery and proximal popliteal artery was associated with better acute angiographic results and improved patency compared with balloon angioplasty alone. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00673985.
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                Author and article information

                Contributors
                Seung-Woon Rha:
                ORCID: http://orcid.org/0000-0002-9157-1401
                swrha617@163.com
                Journal
                Journal ID (nlm-ta): BMC Cardiovasc Disord
                Journal ID (iso-abbrev): BMC Cardiovasc Disord
                Title: BMC Cardiovascular Disorders
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1471-2261
                Publication date (Electronic): 30 June 2021
                Publication date PMC-release: 30 June 2021
                Publication date Collection: 2021
                Volume: 21
                Electronic Location Identifier: 323
                Affiliations
                [1 ]GRID grid.415444.4, Department of Medicine, , The Second Affiliated Hospital of Kunming Medical University, ; Kunming, Yunnan China
                [2 ]GRID grid.411134.2, ISNI 0000 0004 0474 0479, Cardiovascular Center, , Korea University Guro Hospital, ; 148, Gurodong-ro, Guro-gu, Seoul, 08308 Republic of Korea
                [3 ]GRID grid.412674.2, ISNI 0000 0004 1773 6524, Department of Cardiology, , Soon Chun Hyang University Gumi Hospital, ; Gumi-si, Republic of Korea
                [4 ]GRID grid.412677.1, ISNI 0000 0004 1798 4157, Department of Cardiology, , Soonchunhyang University Cheonan Hospital Korea, ; Cheonan-Ii, Republic of Korea
                [5 ]GRID grid.258676.8, ISNI 0000 0004 0532 8339, Department of Internal Medicine, School of Medicine, , Konkuk University, ; Chungju, Republic of Korea
                Author information
                http://orcid.org/0000-0002-9157-1401
                Article
                Publisher ID: 2141
                DOI: 10.1186/s12872-021-02141-z
                PMC ID: 8246708
                PubMed ID: 34193057
                SO-VID: 0c717ca5-60eb-4638-a949-85e4b3eee50f
                Copyright © © The Author(s) 2021
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                Date received : 17 November 2020
                Date accepted : 24 June 2021
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2021

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: chronic outward force,superficial femoral artery,self-expanding nitinol stents,stent oversizing,histomorphometry
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: chronic outward force, superficial femoral artery, self-expanding nitinol stents, stent oversizing, histomorphometry

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