Although reported in bare metal stents (BMS) and first-generation drug-eluting stents (DES), little is known about neoatherosclerosis in second-generation DES. We used optical coherence tomography to evaluate neoatherosclerosis among different stent generations. Overall, 274 in-stent restenosis (ISR) lesions (duration from implantation 56.9 ± 47.2 months) in 274 patients were assessed for the presence of neoatherosclerosis. Neoatherosclerosis was identified in 38.7% of lesions (106/274): 23.0% second-generation DES (38/165), 65.1% first-generation DES (54/83), and 53.8% BMS (14/26). In the neoatherosclerosis cohort (n = 106), more stent underexpansion or fracture/deformation was observed in second-generation DES, whereas thrombus, without plaque rupture, or evagination was more common in first-generation DES. In multivariable analyses, duration from implantation >1 year (OR: 2.44, 95% CI 1.12-5.31; p = 0.03), absence of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (OR 1.95, 95% CI 1.10-3.44; p = 0.02) or statins at the time of ISR (OR 3.12, 95% CI 1.42-6.84; p = 0.01), and first-generation vs first-generation DES (OR 5.32, 95% CI 2.82-10.10; p < 0.001) correlated with a higher prevalence of neoatherosclerosis. Duration from implantation <1 year (OR 2.17, 95% CI 1.03-4.55; p = 0.04) and thin fibrous cap, thrombus, or rupture (OR 2.72, 95% CI 1.15-6.39; p = 0.02) were independent predictors for acute coronary syndromes presentation. Neoatherosclerosis is an important ISR mechanism, especially in first generation DES.
Keywords: Bare metal stent; Drug-eluting stent; Imaging; In-stent restenosis; Optical coherence tomography.