Pathology of Neointimal Calcification in Very Late Restenosis After Bare Metal Stent Implantation for Superficial Femoral Artery

Abstract

SummaryA 60-year-old man, who had claudication in his right limb due to total occlusion of the right superficial femoral artery, received bare metal stents. Although the bare metal stents in the superficial femoral artery did not show restenosis 5 years after stent implantation, angiography revealed significant in-stent restenosis when he developed right critical limb ischemia at 8 years post implantation. Ballooning for in-stent lesions did not result in full expansion. His right limb was amputated above the knee due to progressive limb ischemia. In the pathological findings in the superficial femoral artery, marked calcification was observed in the entire circumference of the luminal surface of the neointima. However, lipid core formation was not identified in the neointima. Although several cracks following balloon angioplasty were observed at the superficial calcified layers, injury to neointimal tissue such as compression was not observed. The neointima exhibited heavy calcification in the very late phase of in-stent restenosis after bare metal stent implantation in superficial femoral artery. Therefore, balloon angioplasty in the very late phase of in-stent restenosis potentially results in underexpansion. (Int Heart J 2017; 58: 641-644) Key words: Endovascular therapy, Neoatherosclerosis, Peripheral artery E ndovascular therapy (EVT) for superficial femoral artery (SFA) stenosis has become a common treatment. 1)When preforming EVT for SFA lesions, bare metal stents (BMSs) are often implanted.2) The efficacy of primary stenting using self-expanding nitinol stents has been widely reported and the clinical outcomes of EVT for SFA lesions have been improved by the use of self-expanding nitinol stents. 3)Even if early restenosis within 1 year can be prevented, there is still the potential for restenosis in the late and very late phases after BMS implantation. However, late and very late vascular responses have not been evaluated. Here, we report a case of major amputation with very late restenosis after BMS implantation for SFA and also present the pathological findings. Case ReportA 60-year-old man, who was on hemodialysis due to diabetes and had a past history of angina and cerebral infarction, had claudication of Rutherford class 3 in his right lower limb due to peripheral artery disease. Angiography showed chronic total occlusion (CTO) of the right SFA ( Figure 1A). Because his symptom continued at the same level despite appropriate medical therapy, he underwent EVT for right SFA. Two BMSs (Zilver [Cook Medical, Bloomington, Indiana] 6.0 mm*60 mm stent in the proximal lesion and Zilver 6.0 mm*80 mm stent in the distal lesion) were implanted ( Figure 1B). After performing EVT, his ankle-brachial index improved from 0.32 to 0.89 and his symptom disappeared. Five years after BMS implantation, his symptom recurred due to a new and short de novo stenosis that was situated at a proximal site in the right SFA segment that received a BMS. Therefore, he underwent plain old balloon angioplasty (POBA) for the de n...

Very late intrastent thrombotic occlusion caused by neoatherosclerosis after bare-metal stent implantation in the superficial femoral artery: Insight from histopathological findings

“…However, in the lower limb arteries, the neoatherosclerotic changes in the neointima after BMS implantation have never been reported before. Previous studies demonstrated that unlike coronary arteries, lower limb arteries show a slow progression of intimal thickening and have heavy calcification and little atherosclerosis plaque [7,8]. And angioscopic assessment also suggested that the mechanism of the development of ISO may be the partial progression of organic stenosis in stent site followed by thrombus formation [9].…”

Exacerbated Peri-Stent Contrast Staining on Serial Angiography and Optical Coherence Tomography After Platinum-Chromium Everolimus-Eluting Stent Implantation for Infrapopliteal Artery Lesions

“…evascularization for peripheral artery disease is shifting to endovascular therapy (EVT) because of development of less invasive devices and techniques. 1,2) There have been several recent reports of acceptable outcomes of infrapopliteal EVT for patients with critical limb ischemia (CLI). 3,4) However, conventional balloon angioplasty (POBA) for infrapopliteal artery lesions has high restenosis and re-intervention rates.…”