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Background: Clinical and morphological factors associated with lipidic versus calcified neoatherosclerosis within second-generation drug-eluting stents and the impact of lipidic versus calcified neoatherosclerosis on long-term outcomes after repeat intervention have not been well studied. Methods: A total of 512 patients undergoing optical coherence tomography before percutaneous coronary intervention for second-generation drug-eluting stents in-stent restenosis were included. Neoatherosclerosis was defined as lipidic or calcified neointimal hyperplasia in ≥3 consecutive frames or ruptured lipidic neointimal hyperplasia. The primary outcome was target lesion failure (cardiac death, target vessel myocardial infarction, definite stent thrombosis, or clinically driven target lesion revascularization). Results: The overall prevalence of neoatherosclerosis was 28.5% (146/512): 56.8% lipidic, 30.8% calcified, and 12.3% both lipidic and calcific. The prevalence increased as a function of time from stent implantation: 20% at 1 to 3 years, 30% at 3 to 7 years, and 75% >7 years. Renal insufficiency, poor lipid profile, and time from stent implantation were associated with lipidic neoatherosclerosis, whereas severe renal insufficiency, female sex, and time from stent implantation were associated with calcified neoatherosclerosis. Multivariable Cox regression revealed that female sex and lipidic neoatherosclerosis were associated with more target lesion failure, whereas stent age and final minimum lumen diameter after reintervention were related to lower target lesion failure. Calcified neoatherosclerosis was not related to adverse events after reintervention for in-stent restenosis given a large enough minimum lumen diameter was achieved. Conclusions: Lipidic but not calcified neoatherosclerosis was associated with poor subsequent outcomes after repeat revascularization if optimal stent expansion was achieved in lesions with calcified neoatherosclerosis.

Background: Coronary calcification inhibits stent expansion. We sought to establish an intravascular ultrasound–derived calcium score to predict stent underexpansion. Methods: This is a retrospective observational study including de novo lesions that underwent intravascular ultrasound–guided stenting and had maximum superficial calcium angle >270°. Lesions with angiographic calcium not treated with atherectomy or scoring/cutting balloon before stent implantation were randomly divided into derivation and validation cohorts. The end point was stent expansion (minimum stent area/average of reference lumen area) at the maximum calcium site, and stent expansion Results: The morphological characteristics associated with stent underexpansion in derivation cohort were (1) superficial calcium angle >270° longer than 5 mm (regression coefficient, −13.0 [95% CI, −18.1 to −7.8], P P =0.001), (3) calcified nodule (regression coefficient, −8.3 [95% CI, −14.3 to −2.2], P =0.007), and (4) vessel diameter P =0.006). The calcium score (0-4) was significantly correlated with poor stent expansion (regression coefficient, −8.1 [95% CI, −10.5 to −5.7], P P P interaction =0.02). In lesions without angiographic calcium, all calcium severity parameters were less than in the validation cohort, and stent underexpansion was observed in only 1.5% (1/67) of lesions. Conclusions: This intravascular ultrasound calcium score provides the interventionalists with a reliable tool to identify calcified stenoses at risk for stent underexpansion and requiring adjunctive calcium modification before stent implantation.