A Patient with Repeated Catastrophic Multi-Vessel Coronary Spasm after Zotarolimus-Eluting Stent Implantation

Abstract

Drug-eluting stents (DES) have gained great popularity because of extraordinarily low rates of restenosis. Despite these superior clinical outcomes, several cases regarding the severe multi-vessel coronary spasm, although rare, after the placement of first generation DES have been reported. We report a case of severe, multi-vessel coronary spasm that occurred two occasions after placement of a zotarolimus-eluting stent, one of the second generation DES, in a 42-year-old man with unstable angina. The first incidence was relieved by intracoronary nitroglycerin alone, and second incident, which had combined fixed stenosis was treated with intracoronary nitroglycerin and everolimus-eluting stent.

A Discussion of the Role of Complex Evolved Systems in the Development of Invasive Cardiovascular Interventions as Illustrated by the Blalock- Taussig Shunt and Intra-Arterial Stents

“…Pigs also develop and eosinophilic inflammation in response to basically all stent implantation [272]. Dogs, sheep and NHPs also demonstrate significant difference from humans in terms of stent response [272]. All of this calls into question Perkins' claim of predictive value for animal models of intra-arterial stents.…”

“…But the stents also led to the problem of subacute thrombosis and in-stent neointimal hyperplasia from scar tissue growth-intimal proliferation [271]. Despite the failure of animal models referred to above, Perkins states: "Because of the complex, multidisciplinary, and dynamic nature of this technology, thorough evaluation of DES systems in preclinical models is crucial for predicting clinical safety and efficacy as well as for providing details into the pathophysiology of the vascular response to injury and restenosis" [272]. Clearly Perkins is claiming that animal models have predictive value.…”

“…These include dogs, nonhuman primates, rabbits, rodents, sheep, and swine [272]. None of the models demonstrates the underlying atherosclerosis of humans.…”

“…Of the pig model for restenosis, Perkins states: "The neointimal response is of a similar histology to that in restenotic human coronary arteries; however, as with other preclinical models, the degree of restenosis often is not sufficient to be of clinical significance even with heightened injury through overstretch models" [272]. Pigs also develop and eosinophilic inflammation in response to basically all stent implantation [272]. Dogs, sheep and NHPs also demonstrate significant difference from humans in terms of stent response [272].…”

“…Perkins also states that as these models do not exhibit atherosclerosis, it must be induced in some fashion and thus: "These models have limited application: There is little thrombus formation, and the induced neointimal hyperplasia tends to be smooth muscle cell rich with little resemblance to human pathology specimens" [272]. Of the pig model for restenosis, Perkins states: "The neointimal response is of a similar histology to that in restenotic human coronary arteries; however, as with other preclinical models, the degree of restenosis often is not sufficient to be of clinical significance even with heightened injury through overstretch models" [272]. Pigs also develop and eosinophilic inflammation in response to basically all stent implantation [272].…”