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A cluster of black holes and multiple plaque ruptures on optical coherence tomography 13 years after bare-metal stent implantation
International Journal of Cardiology 152 (2011) e47–e48
Contents lists available at ScienceDirect
International Journal of Cardiology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d
Letter to the Editor
A cluster of black holes and multiple plaque ruptures on optical coherence tomography 13 years after bare-metal stent implantation Shinji Inaba a, Hideki Okayama a,⁎, Tatsunori Takahashi b, Haruhiko Higashi a, Kazuhisa Nishimura a, Katsuji Inoue a, Akiyoshi Ogimoto a, Jitsuo Higaki a a b
Division of Cardiology, Department of Integrated Medicine and Informatics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan Ehime University Graduate School of Medicine, Toon, Ehime, Japan
a r t i c l e
i n f o
Article history: Received 25 October 2010 Accepted 26 October 2010 Available online 15 December 2011
A 69-year-old man underwent percutaneous coronary intervention with bare-metal stent placement (BMS, Palmaz–Schatz) to the right coronary artery because of ST-segment elevation myocardial infarction in March 1997. Thereafter, the patient was stable during a period of follow-up for 13 years. However, in May 2010, the patient
was readmitted for coronary angiography because of a relapse of angina symptoms. Coronary angiography showed severe in-stent restenosis with ulcer-like formation (Fig. 1). The finding of neointimal hyperplasia was observed on optical coherence tomography (OCT) (Fig. 2). Lipid-laden intima and white thrombus were observed in the distal part of the stent (Fig. 2B and C). OCT also revealed a “honeycomb structure” that had 3 cavities (Fig. 2D) and a cluster of “black holes” that had multiple small vesicular or tubular structures and were present in more than 3 consecutive frames in the midportion of the stent (Fig. 2E). All 3 compartments of the honeycomb structure between the vessel lumen and stent struts demonstrated plaque rupture. Prati et al. demonstrated that thin black holes on OCT are likely due to plaque angiogenesis [1]. However, it remains unclear
Fig. 1. A: Coronary artery angiogram of the RCA 13 years after bare-metal stent (BMS) implantation. B: Enlarged image showing in-stent restenosis with ulceration. White arrow; ulcer-like formation, RCA; right coronary artery.
⁎ Corresponding author. Tel.: +81 89 960 5302; fax: +81 89 960 5306. E-mail address: [email protected] (H. Okayama). 0167-5273/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2010.10.100
e48
S. Inaba et al. / International Journal of Cardiology 152 (2011) e47–e48
Fig. 2. OCT findings of neointimal hyperplasia 13 years after BMS implantation. A: Distal part of the stent showing minimal amounts of neointimal hyperplasia. B: Lipid-laden intimal hyperplasia. C: White thrombus without signal attenuation. D–D': Honeycomb structure with multiple plaque ruptures. E–E': Cluster of black holes in mid-portion of the stent. Green arrows, lipid pool located at 3–11 o'clock; Blue arrow, white thrombus; Yellow arrows, multiple plaque ruptures; White arrows, cluster of black holes; OCT, optical coherence tomography. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
whether the clusters of “black holes” seen are in fact vascular beds arising from neovascularization or abnormal cystic changes in response to BMS implantation. Despite the efficacy and stability of coronary stenting in the medium-term, very late abnormal intimal remodeling can be seen. The mechanism of this atherosclerotic progression is still obscure. Neointimal hyperplasia 13 years after BMS implantation showed a variety of morphological alterations, including novel findings. OCT is a useful imaging modality to detect these changes and further investigation using OCT may reveal the possible pathophysiological mechanism. Acknowledgment The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [2].
Reference [1] Prati F, Regar E, Mintz GS, et al. Expert's OCT Review Document. Expert review document on methodology, terminology, and clinical applications of optical coherence tomography: physical principles, methodology of image acquisition, and clinical application for assessment of coronary arteries and atherosclerosis. Eur Heart J 2010;31:401–15. [2] Shewan LG, Coats AJ. Ethics in the authorship and publishing of scientific articles. Int J Cardiol 2010;144:1–2.
Contents lists available at ScienceDirect
International Journal of Cardiology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d
Letter to the Editor
A cluster of black holes and multiple plaque ruptures on optical coherence tomography 13 years after bare-metal stent implantation Shinji Inaba a, Hideki Okayama a,⁎, Tatsunori Takahashi b, Haruhiko Higashi a, Kazuhisa Nishimura a, Katsuji Inoue a, Akiyoshi Ogimoto a, Jitsuo Higaki a a b
Division of Cardiology, Department of Integrated Medicine and Informatics, Ehime University Graduate School of Medicine, Toon, Ehime, Japan Ehime University Graduate School of Medicine, Toon, Ehime, Japan
a r t i c l e
i n f o
Article history: Received 25 October 2010 Accepted 26 October 2010 Available online 15 December 2011
A 69-year-old man underwent percutaneous coronary intervention with bare-metal stent placement (BMS, Palmaz–Schatz) to the right coronary artery because of ST-segment elevation myocardial infarction in March 1997. Thereafter, the patient was stable during a period of follow-up for 13 years. However, in May 2010, the patient
was readmitted for coronary angiography because of a relapse of angina symptoms. Coronary angiography showed severe in-stent restenosis with ulcer-like formation (Fig. 1). The finding of neointimal hyperplasia was observed on optical coherence tomography (OCT) (Fig. 2). Lipid-laden intima and white thrombus were observed in the distal part of the stent (Fig. 2B and C). OCT also revealed a “honeycomb structure” that had 3 cavities (Fig. 2D) and a cluster of “black holes” that had multiple small vesicular or tubular structures and were present in more than 3 consecutive frames in the midportion of the stent (Fig. 2E). All 3 compartments of the honeycomb structure between the vessel lumen and stent struts demonstrated plaque rupture. Prati et al. demonstrated that thin black holes on OCT are likely due to plaque angiogenesis [1]. However, it remains unclear
Fig. 1. A: Coronary artery angiogram of the RCA 13 years after bare-metal stent (BMS) implantation. B: Enlarged image showing in-stent restenosis with ulceration. White arrow; ulcer-like formation, RCA; right coronary artery.
⁎ Corresponding author. Tel.: +81 89 960 5302; fax: +81 89 960 5306. E-mail address: [email protected] (H. Okayama). 0167-5273/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2010.10.100
e48
S. Inaba et al. / International Journal of Cardiology 152 (2011) e47–e48
Fig. 2. OCT findings of neointimal hyperplasia 13 years after BMS implantation. A: Distal part of the stent showing minimal amounts of neointimal hyperplasia. B: Lipid-laden intimal hyperplasia. C: White thrombus without signal attenuation. D–D': Honeycomb structure with multiple plaque ruptures. E–E': Cluster of black holes in mid-portion of the stent. Green arrows, lipid pool located at 3–11 o'clock; Blue arrow, white thrombus; Yellow arrows, multiple plaque ruptures; White arrows, cluster of black holes; OCT, optical coherence tomography. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
whether the clusters of “black holes” seen are in fact vascular beds arising from neovascularization or abnormal cystic changes in response to BMS implantation. Despite the efficacy and stability of coronary stenting in the medium-term, very late abnormal intimal remodeling can be seen. The mechanism of this atherosclerotic progression is still obscure. Neointimal hyperplasia 13 years after BMS implantation showed a variety of morphological alterations, including novel findings. OCT is a useful imaging modality to detect these changes and further investigation using OCT may reveal the possible pathophysiological mechanism. Acknowledgment The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [2].
Reference [1] Prati F, Regar E, Mintz GS, et al. Expert's OCT Review Document. Expert review document on methodology, terminology, and clinical applications of optical coherence tomography: physical principles, methodology of image acquisition, and clinical application for assessment of coronary arteries and atherosclerosis. Eur Heart J 2010;31:401–15. [2] Shewan LG, Coats AJ. Ethics in the authorship and publishing of scientific articles. Int J Cardiol 2010;144:1–2.