Prevalence, Features, and Prognostic Importance of Edge Dissection After Drug-Eluting Stent Implantation

The main mechanisms of percutaneous coronary intervention (PCI) with stent implantation are vessel expansion and plaque redistribution, and one of the major complications is dissection originating from the proximal or distal stent edge. Although angiographic criteria for a significant dissection have been published, the criteria for a significant intravascular ultrasound (IVUS)–detected stent edge dissection have not been established. ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) was a large-scale, prospective, multicenter study designed to assess the relationship between platelet reactivity and other clinical and procedural variables and subsequent stent thrombosis and adverse clinical events in patients successfully treated with drug-eluting stents (DES). In a prespecified, prospective IVUS substudy, lesions were evaluated and treated using IVUS-guided PCI. The aims of the current study were to (1) determine the prevalence of stent edge dissection in the contemporary DES era; (2) evaluate the morphological features of stent edge dissection; (3) clarify outcomes related to untreated stent edge dissections detected by IVUS; and (4) identify criteria for a significant IVUS-detected stent edge dissection that might warrant treatment with additional stent implantation at the time of PCI. Background—Intravascular ultrasound detects stent edge dissections after percutaneous coronary intervention that are not seen angiographically. This study investigated the association between stent edge dissections and clinical outcomes. Methods and Results—ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) was a largescale, prospective, multicenter study of patients undergoing drug-eluting stent implantation. In this prospective substudy, 2062 patients (2433 lesions) were evaluated with intravascular ultrasound to characterize the morphological features and clinical outcomes of stent edge dissection after percutaneous coronary intervention. The prevalence of post–percutaneous coronary intervention stent edge dissection was 6.6% per lesion (161 of 2433). Calcified plaque at the proximal stent edge (relative risk [RR]=1.72; P=0.04) and proximal stent edge expansion (RR=1.18; P=0.004) were predictors for proximal dissection; attenuated plaque at the distal stent edge (RR=3.52; P=0.004), distal reference plaque burden (RR=1.56; P<0.0001), and distal edge stent expansion (RR=1.11; P=0.02) were predictors for distal dissection. At 1-year follow-up, target lesion revascularization was more common in lesions with versus without dissection (5.2% versus 2.7%; P=0.04). Multivariable analysis indicated that residual dissection was associated with target lesion revascularization at 1-year follow-up (RR=2.67; P=0.02). Among lesions with dissection, smaller effective lumen area increased the risk of target lesion revascularization at 1-year follow-up (cutoff value of 5.1 mm; P=0.05). Conclusions—Greater stent expansion and the presence of large, calcified, and/or attenuated plaques were independent predictors of stent edge dissection. Residual stent edge dissection, especially with a smaller effective lumen area, was associated with target lesion revascularization during 1-year follow-up after drug-eluting stent implantation. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00638794. (Circ Cardiovasc Interv. 2016;9:e003553. DOI: 10.1161/CIRCINTERVENTIONS.115.003553.)