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. 2023 Sep 1;13(9):6037-6047.
doi: 10.21037/qims-23-414. Epub 2023 Aug 3.

Impact of plaque characteristics on percutaneous coronary intervention-related microvascular dysfunction: insights from angiographic microvascular resistance and intravascular ultrasound

Jianchang Xie  1 , Ying He  2 , Hao Ji  2 , Qingqing Hu  2 , Senjiang Chen  2 , Beibei Gao  1 , Jianmin Yang  1 , Xiangbo Jin  1 , Liang Zhou  1 , Ningfu Wang  1 , Xiaoshan Tong  1 , Guoxin Tong  1 , Jinyu Huang  1
Affiliations

Impact of plaque characteristics on percutaneous coronary intervention-related microvascular dysfunction: insights from angiographic microvascular resistance and intravascular ultrasound

Jianchang Xie et al. Quant Imaging Med Surg. .

Abstract

Background: The correlation between percutaneous coronary intervention (PCI)-related microvascular dysfunction (MVD) and plaque characteristics remains unclear. To investigate this correlation and its prognosis, we assessed changes in MVD by angiographic microvascular resistance (AMR) and intracoronary ultrasound scans after PCI.

Methods: We conducted a retrospective study that enrolled 250 patients with coronary artery disease between July 2016 and December 2018. We collected demographic characteristics, laboratory tests, coronary angiography (CAG) and intracoronary ultrasound findings. We calculated quantitative flow ratio (QFR) and AMR by CAG. The endpoint was vessel-oriented composite outcomes (VOCOs).

Results: After 47 exclusions, we divided 203 cases into a deteriorated group (n=139) and an improved group (n=64) based on AMR change after PCI. Compared with the improved group, the deteriorated group had smaller lumen area [3.03 (interquartile range, 2.20-3.91) vs. 3.55 mm2 (interquartile range, 2.45-4.57), P=0.033], higher plaque burden [78.92% (interquartile range, 73.95-82.61%) vs. 71.93% (interquartile range, 62.70-77.51%), P<0.001], and higher proportion of lipidic components (13.86%±4.67% vs. 11.78%±4.41%, P=0.024). Of 186 patients who completed 4.81±1.55 years follow-up, 56 developed VOCOs. Receiver-operating characteristic (ROC) curve analysis showed post-PCI AMR and VOCOs correlation (area under the curve: 0.729, P<0.001). Multivariate regression analysis showed post-PCI AMR >285 mmHg·s/m correlated with adverse outcome (hazard ratio =4.350; 95% confidence interval: 1.95-9.703; P<0.001).

Conclusions: Intravascular ultrasound (IVUS) imaging and AMR revealed an association of post-PCI MVD with a smaller lumen area, more severe plaque burden, and a higher percentage of lipidic components. Post-PCI MVD was an independent risk factor for poor prognosis.

Keywords: Percutaneous coronary intervention (PCI); coronary angiography (CAG); intravascular ultrasound (IVUS); microvascular dysfunction (MVD); plaque characteristics.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-23-414/coif). JX received grants from the Hangzhou Agricultural and Social Development Scientific Research Project (No. 20220919Y066). JH received grants from Funds for International Cooperation and Exchange of the National Natural Science Foundation of China (No. 62161160312) and Zhejiang Provincial Key Research and Development Program (No. 2020C03018). The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Examples of QFR and AMR analysis. CAG showed a stenosis in the proximal left anterior descending, and QFR was calculated as 0.77, flow velocity was 15.0 cm/s, AMR was calculated as 214 mmHg·s/m (A). After stent implantation, QFR was calculated as 0.98, flow velocity was 13.3 cm/s, and AMR was calculated as 291 mmHg·s/m (B). QFR, quantitative flow ratio; AMR, angiographic microvascular resistance; CAG, coronary angiography.
Figure 2
Figure 2
Examples of intracoronary ultrasound analysis of a plaque. A representative IVUS image of microvascular deterioration after PCI. EEM was 15.20 mm2, lumen CSA was 2.26 mm2, and plaque burden was 85% of (EEM-lumen CSA)/EEM. In terms of plaque composition, fibrotic: 55%, lipidic: 18%, necrotic: 24%, and calcified: 2% representatively (A). A representative IVUS image of microvascular improved after PCI. EEM was 15.50 mm2, lumen CSA was 4.0 mm2, and plaque burden was 74%. The ratio of plaque was fibrotic: 80%, lipidic: 8%, necrotic: 11%, and calcified: 1% representatively (B). TA, trace areas; CL, confidence level; IVUS, intracoronary ultrasound; PCI percutaneous coronary intervention; EEM external elastic membrane; CSA cross sectional area.
Figure 3
Figure 3
Receiver-operating characteristic curve analysis. Post-PCI AMR, plaque burden, lumen CSA, pre-PCI QFR and VOCOs were correlated with area under the curve of 0.729, 0.617, 0.606 and 0.589, respectively, with P values of <0.001, 0.012, 0.022, and 0.033. PCI, percutaneous coronary intervention; AMR, angiographic microvascular resistance; CSA, cross-sectional area; PCI, percutaneous coronary intervention; QFR, quantitative flow ratio; VOCOs, vessel-oriented composite outcomes.
Figure 4
Figure 4
Cumulative incidence of VOCOs. Kaplan-Meier curves showing the cumulative incidence of VOCOs in patients with high and low AMR based on a cutoff value of 285 derived from the ROC curve. The P values were calculated with the log-rank test. When using an AMR cutoff of 285 mmHg·s/m derived from the ROC curve for predicting VOCOs, the cumulative incidence of VOCOs, myocardial infarction, revascularization, and cardiac death was significantly higher in patients with an AMR >285 mmHg·s/m (red line) than in those with an AMR of ≤285 mmHg·s/m (blue line) (P<0.001, P=0.065, P<0.001, P=0.010 respectively). AMR, angiographic microvascular resistance; VOCOs, vessel-oriented composite outcomes; ROC, receiver-operating characteristic.
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