Flow instabilities induced by coronary artery stents: assessment with an in vitro pulse duplicator

An in vitro pulse duplicator system was used to investigate whether coronary artery stents induce downstream flow instabilities. Hot film or electrochemical probes were used to measure wall shear stress before and after deployment of both single and multiple (overlapping) stents in normal and diseased coronary geometries. Left main coronary diameters ranged from 4 to 5 mm, whereas left anterior descending (LAD) and left circumflex (LCX) diameters ranged from 2 to 4 mm. Under resting conditions, all coronary flow waveforms remained laminar, even after stent placement. However, disturbances were found downstream from a stent placed in the proximal LAD under mild exercise conditions. These disturbances were found 5 mm distal to the stent, in both the LAD and the proximal LCX. Turbulence intensities of order 5% were induced by a single slotted stent in a normal LAD geometry. In cases of distal disease, the turbulence intensity was 9% with one stent and 11% with tandem stents. In cases of proximal disease, these values were 19 and 25%, respectively. The shear stress from these disturbances (20-200 dynes cm-2) is sufficient to delay re-endothelialization and promote restenosis. Therefore, the disturbances could contribute to the increased incidence of restenosis reported with multiple stents, and with stents used in cases of diffuse coronary disease.