Very Late Stent Thrombosis Associated With Multiple Stent Fractures and Peri-Stent Aneurysm Formation After Sirolimus-Eluting Stent Implantation

Abstract

revious randomized trials have shown that drugeluting stents (DES) are superior to bare-metal stents (BMS) in reducing the need for target lesion revascularization, but safety issues with DES have recently been raised. Case ReportIn February 2004, a 64-year-old man underwent percutaneous coronary intervention (PCI) for total occlusion of the proximal left anterior descending artery (LAD) using a 3.5×20 mm Tsunami stent™ (Terumo, Tokyo, Japan) under the diagnosis of subacute myocardial infarction. Routine follow-up coronary angiography at 6 months after PCI showed no in-stent restenosis, but there was significant stenosis of the mid-LAD bifurcation portion, so we deployed a 3.0× 33 mm Cypher stent™ (Cordis, Johnson & Johnson, New Brunswick, NJ, USA) inflated to 14 atm. Afterwards, the 2 nd diagonal branch (D2) of the LAD was compromised, so we dilated the lesion using a kissing balloon technique. Final coronary angiography showed no residual stenosis. That night, the patient suffered sudden severe anterior chest pain and the electrocardiogram (ECG) showed new T-wave inversion and ST-segment depression in the V3-6 leads. Emergency coronary angiography showed that the distal flow was good and the stent in the mid-LAD was patent, but D2 was compromised because of dissection. We deployed a 2.5×23 mm Cypher stent™ at 14 atm for D2, and then ballooned into the LAD with a reversed crush technique using a 3.0-mm balloon catheter. We performed a final kissing balloon dilation for the LAD and D2 (Fig 1). In March, 2005, repeat follow-up coronary angiography showed no in-stent restenosis, but there was mild peri-stent aneurysm Circulation Journal Vol.72, July 2008 formation in the mid-LAD. The patient had no cardiac symptoms during clinical follow-up after the second followup angiogram, and medical treatment was continued with aspirin 200 mg/day, a -blocker and a statin. In June 2007, the patient was admitted with gall stones and intestinal ileus. During treatment he stopped taking aspirin for 3 days and the next day, 35 months after Cypher™ stenting, he was taken to the emergency room because of severe squeezing chest pain for 1 h; the ECG showed tall T wave in the anterior wall (ie, regional wall motion abnormality) (Fig 2). The levels of cardiac enzymes were within the normal ranges [creatine kinase (CK): 36 U/L, CK-MB: 0.3 ng/ml, troponin I: 0.0 ng/ml]. Urgent coronary angiography revealed a patent BMS in the proximal LAD, but the sirolimus-eluting stents (SES) in the mid-LAD and D2 were totally occluded by massive thrombosis. Peri-stent aneurysmal dilation and 5-segment stent strut fractures were noted ( Figs 3A,B). We tried to cross the occlusion site using a guidewire, but were prevented by the severe displacement of the stent fracture Circ J 2008; 72: 1201 -1204 (Received September 19, 2007 revised manuscript received November 14, 2007; accepted December 11, 2007

A Case of a Zotarolimus-Eluting Stent Fracture in the Left Anterior Descending Artery in a Patient Undergoing Hemodialysis

“…In this case, we performed revascularization because the patient complained of angina and there was a risk of stent thrombosis or localized aneurysm formation 11-14. We successfully treated the patient with a different kind of open-cell-designed short stent implantation.…”

Clinical outcomes and optimal treatment for stent fracture after drug-eluting stent implantation

“…Many studies have suggested that one of the causes of post-DES restenosis is stent fracture (SF) [2,3]. The SF was usually detected at a routine follow-up coronary angiography incidentally, but some cases were related to in-stent restenosis or presented with late stent thrombosis [4][5][6][7]. Thus, in the era of DES, coronary SF rarely develops, but is one of the important problems.…”

Comparison between Plain Old Balloon Angioplasty and Drug‐Eluting Stent Implantation for the Treatment of Stent Fracture

“…Although the reasons for this are not entirely clearly inadequate drug delivery, delayed re-endothealization, aneurism formation at SF site, and interaction between activated platelet and exposure to fractured strut might be some of the mechanisms that have been proposed for such events as suggested in the previous reports. [12][13][14][15][16] The optical coherence tomography (OCT) study by Kashiwagi et al 17 demonstrated that neointimal hyperplasia is more likely to occur at the site of SF where strut separation might prevent adequate drug delivery, a factor known to predispose to ISR. 18 This may explain at least to some extent why further DES implantation at the SF site appears to be superior to POBA alone.…”