Fracture of a paclitaxol-eluting stent implanted for in-stent restenosis at the site of sirolimus-eluting stent fracture

Fracture of a paclitaxol-eluting stent implanted for in-stent restenosis at the site of sirolimus-eluting stent fracture

International Journal of Cardiology 140 (2010) e12 – e13 www.elsevier.com/locate/ijcard Letter to the Editor Fracture of a paclitaxol-eluting stent ...

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International Journal of Cardiology 140 (2010) e12 – e13 www.elsevier.com/locate/ijcard

Letter to the Editor

Fracture of a paclitaxol-eluting stent implanted for in-stent restenosis at the site of sirolimus-eluting stent fracture Toru Watanabe a , Akira Tamura b,⁎, Kumie Miyamoto a , Junichi Kadota b a

Division of Cardiovascular Medicine, Oita Nakamura Hospital, Oita, Japan b Second Department of Internal Medicine, Oita University, Yufu, Japan Received 13 May 2008; accepted 9 November 2008 Available online 6 December 2008

Abstract We report a patient with fracture of a paclitaxol-eluting stent implanted for focal in-stent restenosis (ISR) with sirolimus-eluting stent fracture. This case report suggests that a drug-eluting stent (DES) implanted for ISR with DES fracture may develop recurrent stent fracture. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Stent fracture; Sirolimus-eluting stent; Paclitaxol-eluting stent; In-stent restenosis

1. Case report

2. Discussion

A 69-year-old man was admitted to our hospital due to acute inferior myocardial infarction. Emergent coronary angiography (CAG) showed a total occlusion in the right coronary artery (RCA). A bare-metal coronary stent was successfully implanted for the lesion. Three months later, he was again admitted because of anginal attacks. CAG revealed in-stent restenosis (ISR) (Fig. 1A and B). Subsequently, 3 sirolimus-eluting stents (SES) were successfully implanted for the lesions (Fig. 1C). Nine months later, he complained of anginal attacks. CAG showed focal ISR (Fig. 1D) with SES fracture (Fig. 1E, arrow). Subsequently, a paclitaxol-eluting stent (PES) was implanted for the lesion (Fig. 1F). Three months later, he again complained of anginal attacks. CAG revealed focal ISR (Fig. 1G) with PES fracture (Fig. 1H, arrow). Multislice computed tomography clearly showed PES fracture (Fig. 1I). Balloon coronary angioplasty was successfully performed for the lesion.

To the best of our knowledge, this is the first report indicating fracture of a PES implanted for ISR with SES fracture. Recently, drug-eluting stent (DES) fracture has been shown to be associated with an increased risk of ISR [1–5]. In the present case also, focal ISR occurred at the site of stent fracture of both SES and PES. It is guessed that stent fracture may cause a decrease in local drug delivery, an increase in local mechanical stimulation of the vessel wall by broken struts, and loss of mechanical scaffolding of the stent, resulting in focal ISR. Previous studies have identified the stent length, the vessel tortuosity, overlapping stents, saphenous vein graft lesions, RCA lesions, and SES as the independent predictors of DES fracture [1–5]. It the present case, mechanical fatigue is considered to be the major cause of the fractures of both SES and PES, because the fractures occurred at a hinge point of the movement of the RCA with the cardiac cycle. The present case report suggests that DES implanted for ISR with DES fracture may develop recurrent stent fracture. A few reports [3,4] have demonstrated that additional DES implantation was effective for ISR with DES fracture. Lee

⁎ Corresponding author. Second Department of Internal Medicine, Oita University, Idaigaoka 1-1, Hasama-machi, Yufu 879-5593, Japan. Tel.: +81 97 586 5804; fax: +81 97 549 4245. E-mail address: [email protected] (A. Tamura). 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.11.036

T. Watanabe et al. / International Journal of Cardiology 140 (2010) e12–e13

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Fig. 1. (A) (B) Coronary angiograms showing in-stent restenosis (ISR) at the site implanted a bare-metal stent; (C) a coronary angiogram showing a successful dilatation at the sites implanted 3 sirolimus-eluting stents (SES); (D) a coronary angiogram showing focal ISR; (E) a fluoroscopic image showing SES fracture; (F) a coronary angiogram showing a successful dilatation at the site implanted a paclitaxiol-eluting stent (PES); (G) a coronary angiogram showing focal ISR. (H) a fluoroscopic image showing PES fracture at the site of ISR; (I) a multislice computed tomographic image showing PES fracture.

et al. [3] reported that PES implantation was undergone for 3 patients with ISR at the site of SES fracture, resulting in neither recurrent restenosis nor stent fracture. Umeda et al. [5] reported that SES implantation was undergone for 2 patients with ISR at the site of SES fracture were treated with, resulting in neither recurrent restenosis nor stent fracture. Therefore, a DES implanted for ISR with DES fracture does not always appear to develop recurrent stent fracture. Further investigation is needed to clarify the incidence of recurrent fracture of DES implanted for ISR with DES fracture and determine the best treatment for ISR with DES fracture. Acknowledgment The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [6].

References [1] Aoki J, Nakazawa G, Tanabe K, et al. Incidence and clinical impact of coronary stent fracture after sirolimus-eluting stent implantation. Catheter Cardiovasc Interv 2007;69:380–6. [2] Lee MS, Jurewitz D, Aragon J, et al. Stent fracture associated with drugeluting stents: clinical characteristics and implications. Catheter Cardiovasc Interv 2007;69:387–94. [3] Lee SH, Park JS, Shin DG, et al. Frequency of stent fracture as a cause of coronary restenosis after sirolimus-eluting stent implantation. Am J Cardiol 2007;100:627–30. [4] Shaikh F, Maddikunta R, Djelmami-Hani M, et al. Stent fracture, an incidental finding or a significant marker of clinical in-stent restenosis? Catheter Cardiovasc Interv 2008;71:614–8. [5] Umeda H, Gochi T, Iwase M, et al. Frequency, predictors and outcome of stent fracture after sirolimus-eluting stent implantation. Int J Cardiol 2009;133:321–6. [6] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.