![Quantification of Atherosclerotic Plaque Activity and Vascular Inflammation using [18-F] Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG-PET/CT)](/_next/image?url=https%3A%2F%2Fcloudfront.jove.com%2FCDNSource%2Fteasers%2F3777.jpg&w=3840&q=50)
Molecular phenotyping with 18F-FDG and 18F-FAPI PET/CT: advancing risk stratification in in-stent restenosis
Lei Jia1,2,3, Ke Wang4, Zhangyu Lin1,2,3
1Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China.
Purpose:
To investigate the potential of 18F-FDG and 18F-FAPI PET/CT for characterizing the pathophysiological heterogeneity of in-stent stenosis (ISR) and to assess their ability to differentiate between its clinically subtypes.
Methods:
This prospective study enrolled participants with ISR selected from a cohort registry between December 2024 to August 2025, which was categorized into rapid recurrent ISR (R-ISR) and ordinary ISR (O-ISR) based on recurrence time interval. For vessel-level analysis, coronary arteries without intervention served as control. All participants underwent both 18F-FDG and 18F-FAPI PET/CT to assess coronary uptake and evaluated the performance of maximum standardized uptake value (SUVmax) and maximum target-to-background ratio (TBRmax) in differentiating ISR from control vessels, as well as R-ISR from O-ISR. All patients were followed-up. The primary endpoint was a composite of cardiovascular death, target-vessel-related myocardial infarction, or target-vessel-related revascularization. Differences in the diagnostic performance of PET parameters and associations with outcomes were assessed.
Results:
Thirty-one participants and 84 vessels were included. ISR vessels (n = 39) demonstrated higher uptake in 18F-FDG and 18F-FAPI than control (n = 45). R-ISR exhibited higher uptake compared to O-ISR on both patient-level (TBRmax: 18F-FAPI, 4.10 ± 1.41 vs. 1.75 ± 0.50; 18F-FDG, 1.18 ± 0.32 vs. 0.86 ± 0.19) and vessel-level (TBRmax: 18F-FAPI, 4.07 ± 1.29 vs. 1.65 ± 0.50; 18F-FDG, 1.16 ± 0.31 vs. 0.90 ± 0.28) (all P ≤ 0.01). 18F-FAPI showed better diagnostic efficacy compared to 18F-FDG (AUC of TBRmax: 0.97 [0.92-1.00] vs. 0.75 [0.58-0.91], P = 0.01]. Six of 31 participants within R-ISR group reached the endpoint. Baseline PET uptake was associated with subsequent outcome (18F-FAPI SUVmax, HR, 2.28 [95%CI: 1.25-5.09], P = 0.02; 18F-FDG SUVmax, HR, 33.2 [95%CI: 4.93-509], P = 0.002).
Conclusion:
18F-FAPI and 18F-FDG PET/CT reveals the molecular heterogeneity of ISR, with 18F-FAPI better identifying the rapid-recurrence subtype for advancing risk stratification.
Trial Registration:
NCT05437965. Registered 24 June 2022.
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