In‐stent restenotic lesions can rupture—A case against plaque sealing

Abstract

We present a case of plaque rupture located inside a restenotic stent. Intravascular ultrasound defined a lesion with a minimal lumen area (MLA) of 3.59 cm², plaque burden of 72%, and reference vessel luminal diameter of 4.0 mm with an external elastic membrane lumen cross-section area of 12.6 mm². There was a clearly identified plaque rupture, with a flap-like dissection within the stented segment. Virtual histology intravascular ultrasound confirmed that the adjacent plaque had necrotic core with a thin overlying fibrous cap. The remaining tissue next to the dissection plane was fibrotic. This case illustrates that neointimal hyperplasia may organize into an unstable plaque, with a thin fibrous cap overlying a lipid-rich necrotic core-a so-called virtual histology thin-capped fibroatheroma. As defined in the PROSPECT trial, the in-stent stenotic lesion in our case conformed to the definition of a high-risk plaque-it had an MLA < 4 mm², plaque burden was ≥ 70%, and there was >10% necrotic core. It became unstable and ruptured. The demonstrated findings of this case may sway physicians against sealing hemodynamically nonsignificant unstable plaques.

Restenosis

“…Plaque progression and rupture leading to myocardial infarction (MI) have been reported in rare case reports involving BMS 28,29 and more recently DES. 30 The underlying pathological mechanisms are one of necrotic core plaque progression and rupture either within the stent with BMS or at the stent edge in incompletely covered lipid-core plaque with DES (see Implantation Factors).…”

Neoatherosclerosis in the stent

“…Так в одном из клинических случаев на ВСУЗИ с градациями серого была показана кальцифициро-ванная неоинтима через 8 лет после имплантации стента [29]. В других статьях описан разрыв бляшки и клапаннообразная диссекция внутри рестенозирован-ного стента [30,31]. Кроме того, с помощью ВСУЗИ с ВГ обнаружена неонтимальная гиперплазия с нестабиль-ной морфологией, которая схожа по своим свойствам с фиброатеромой с тонкой капсулой.…”