Microvascular and Prognostic Effect in Lesions With Different Stent Expansion During Primary PCI for STEMI: Insights From Coronary Physiology and Intravascular Ultrasound

Abstract

Background: While coronary stent implantation in ST-elevation myocardial infarction (STEMI) can mechanically revascularize culprit epicardial vessels, it might also cause distal embolization. The relationship between geometrical and functional results of stent expansion during the primary percutaneous coronary intervention (pPCI) is unclear.

Objective: We sought to determine the optimal stent expansion strategy in pPCI using novel angiography-based approaches including angiography-derived quantitative flow ratio (QFR)/microcirculatory resistance (MR) and intravascular ultrasound (IVUS).

Methods: Post-hoc analysis was performed in patients with acute STEMI and high thrombus burden from our prior multicenter, prospective cohort study (ChiCTR1800019923). Patients aged 18 years or older with STEMI were eligible. IVUS imaging, QFR, and MR were performed during pPCI, while stent expansion was quantified on IVUS images. The patients were divided into three subgroups depending on the degree of stent expansion as follows: overexpansion (>100%), optimal expansion (80%-100%), and underexpansion (<80%). The patients were followed up for 12 months after PCI. The primary endpoint included sudden cardiac death, myocardial infarction, stroke, unexpected hospitalization or unplanned revascularization, and all-cause death.

Results: A total of 87 patients were enrolled. The average stent expansion degree was 82% (in all patients), 117% (in overexpansion group), 88% (in optimal expansion), and 75% (in under-expansion). QFR, MR, and flow speed increased in all groups after stenting. The overall stent expansion did not affect the final QFR (p = 0.08) or MR (p = 0.09), but it reduced the final flow speed (-0.14 cm/s per 1%, p = 0.02). Under- and overexpansion did not affect final QFR (p = 0.17), MR (p = 0.16), and flow speed (p = 0.10). Multivariable Cox analysis showed that stent expansion was not the risk factor for MACE (hazard ratio, HR = 0.97, p = 0.13); however, stent expansion reduced the risk of MACE (HR = 0.95, p = 0.03) after excluding overexpansion patients. Overexpansion was an independent risk factor for no-reflow (HR = 1.27, p = 0.02) and MACE (HR = 1.45, p = 0.007). Subgroup analysis shows that mild underexpansion of 70%-80% was not a risk factor for MACE (HR = 1.11, p = 0.08) and no-reflow (HR = 1.4, p = 0.08); however, stent expansion <70% increased the risk of MACE (HR = 1.36, p = 0.04).

Conclusions: Stent expansion does not affect final QFR and MR, but it reduces flow speed in STEMI. Appropriate stent underexpansion of 70-80% does not seem to be associated with short-term prognosis, so it may be tolerable as noninferior compared with optimal expansion. Meanwhile, overexpansion and underexpansion of <70% should be avoided due to the independent risk of MACEs and no-reflow events.

Keywords: IVUS; ST-elevation myocardial infarction (STEMI); major adverse cardiovascular events (MACEs); microcirculation; stent expansion.

Figure 1

An example of IVUS imaging and analysis of stent expansion. (A) EEM CSA and lumen CSA of proximal normal-looking segment; (B) EEM CSA and lumen CSA of distal normal-looking segment; (C) EEM CSA and lumen CSA of minimal culprit segment; (D) EEM, CSA, and MSA after stenting, the stent expansion is 13.29/[(14.06+18.61)/2] x 100 = 82.4%. EEM, external elastic membrane; CSA, crosssectional area; MSA, minimum stent cross-sectional area.

Figure 2

An example of plaque analysis. The ratio of plaque is fibrotic: 43%, lipidic: 13%, necrotic: 42%, and calcified: 2% representatively.

Figure 3

An example of QFR and MR analysis. (A,B) Angiographs of two angles of one same culprit lesion; (C) cQFR is 0.9, MR is 211mm Hg*s/m, flow speed is 19.5cm/s. cQFR, contrast-flow quantitative flow ratio; MR, microcirculatory resistance.

Figure 4

Flowchart of study inclusion and exclusion.

Figure 5

Data of QFR characters.

Figure 6

Multivariate Cox regression analyses of stent expansion for prognosis. (A) multivariate regression of no-reflow; (B) multivariate regression of MACE. MACE, major cardiac adverse events.