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Mending the broken stent
G Model JICC 431 No. of Pages 3
Journal of Indian College of Cardiology xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Indian College of Cardiology journal homepage: www.elsevier.com/locate/jicc
Case report
Mending the broken stent Varun Nivargia , C.N. Makhaleb , M.S. Hiremathc a
Cardiology Consultancy, Ruby Hall Clinic, Pune, India Cardiology, Ruby Hall Clinic, Pune, India c Cardiology Consultancy, Ruby Hall Clinic Pune, CSI President India, Pune, India b
A R T I C L E I N F O
Article history: Received 17 January 2017 Accepted 28 August 2017 Available online xxx Keywords: Stent fracture IVUS
A B S T R A C T
A 54-year-old male patient diabetic with history of coronary angioplasty 4 years back with a drug eluting stent presented with anterior wall ST segment Elevation Myocardial Infarction. He was taken up for primary angioplasty, diagnostic angiogram showed 100% thrombotic occlusion of proximal left anterior descending artery with an aneurysm. A stent boost was done which showed a fragmented left anterior descending artery stent with disarticulation of both fragments. Two drug eluting stents one in proximal left anterior descending artery bridging the broken fragments of the previous stent and other in a mid left anterior descending artery lesion of 90% were deployed with excellent angiographic outcome with TIMI III flow. © 2017 Indian College of Cardiology. All rights reserved.
1. Introduction A dramatic revolution in the field of intervention cardiology has been heralded by the use drug-eluting stents (DES) replacing bare metal stents (BMS), and thereby significantly reducing the restenosis rates and the need for repeat revascularization.1 However, the occurrence of late-onset complications, such as stent thrombosis, has raised concern over the use of DES. In addition, there has been an increasing awareness of stent fracture (SF) as a potential complication following DES implantation. Review of the literature shows there is increasing concern about SF as a potential cause of stent restenosis and thrombosis, which can lead to adverse clinical outcomes such as recurrent angina, myocardial infarction (MI), and even sudden death. Coronary SF was first reported in 2002 after a BMS implantation in a venous bypass graft. The first case of coronary DES fracture appeared in 20042 after which several cases of SFs were reported
therapy aspirin 100 mg presented with acute onset chest pain Canadian Classification System grade 4 and New York Heart Association class 4 dyspnoea. Time since onset of symptoms to hospital admission was 90 min. 12 lead electrocardiogram was suggestive of acute Anterior wall ST Elevation Myocardial Infarction. His vitals included heart rate of 108 beats/min sinus rhythm, blood pressure of 80/60 mmHg, respiratory rate of 34 per min with cold extremities. His chest had extensive crepitation's bilaterally . Thus he was in cardiogenic shock. He was on dual inotropic support and non-invasive ventilation. Decision for primary angioplasty was taken with the consent of the relatives. Patient was treated with loading dose of ticagrelor (90 mg two tablets of ticagrelor), 350 mg of aspirin non enteric coated, 80 mg of atorvastatin. 2.1. Course in Cath Lab
2. Case A 54-year-old male patient with history of type 2 diabetes mellitus on oral hypoglycaemic agents and history of angioplasty to left anterior descending artery (LAD) with drug eluting stent (details not known) 4 years back presently on single antiplatelet
He was taken up for primary percutaneous intervention (PCI). Right femoral approach was used. Adequate heparinization was done and patient was started on tirofiban infusion after the initial bolus dose. Diagnostic angiogram showed 100% thrombotic occlusion of proximal left anterior descending artery with an aneurysm (Figs. 1 and 2). Floppy Guide wire was initially thought to have crossed in to the distal LAD, but there was difficulty in
http://dx.doi.org/10.1016/j.jicc.2017.08.003 1561-8811/© 2017 Indian College of Cardiology. All rights reserved.
Please cite this article in press as: V. Nivargi, et al., Mending the broken stent, J Indian Coll Cardiol. (2017), http://dx.doi.org/10.1016/j. jicc.2017.08.003
G Model JICC 431 No. of Pages 3
2
V. Nivargi et al. / Journal of Indian College of Cardiology xxx (2017) xxx–xxx
Fig. 1. Diagnostic coronary angiogram showing proximal LAD total thrombotic occlusion.
crossing the balloon. The aneurysm and thrombus was compounding the problem. Hence a stent boost was done which showed a fragmented LAD stent with disarticulation and displacement of both fragments (type IV stent fracture) (Fig. 3A). The wiring was very challenging as we had to cross through the true lumens of both the stent fragments. We used extra floppy, whisper, cross 100, Gaia II along with help of micro catheter but wire could not be negotiated through lumen of both fragments .All efforts were in vain. Presence of aneurysm, thrombus and dynamic movements of two fragments were complicating the issue. Intravascular ultrasound (IVUS) was advanced over one wire which showed true lumen and false lumen as well as angulations of two fragmented segments. Another buddy wire Gaia II was advanced by the side of IVUS and concurrently using IVUS as well as fluoroscopic image the guide wire was negotiated into the true lumen of Distal fragment. Second guide wire now acted as the primary wire. The entire stent was restudied with IVUS on primary wire. After this thrombus suction and graded balloon dilatation was done. Then two Everolimus drug eluting stents 3.5–48 in proximal LAD bridging the broken fragments of the previous stent (Fig. 3B) and another Everolimus
Fig. 2. Coronary angiogram showing the proximal LAD aneurysm.
eluting stent 3–18 in a mid LAD lesion of 90% were deployed with excellent angiographic outcome with TIMI III flow (Fig. 4). Adequate pre dilatation and post dilatation was done. Intracoronary adenosine, nicorandil was also given. Thus the old fragmented stent was bridged with a long stent. Owing to the poor hemodynamic of the patient he was electively intubated for mechanical ventilation and intra aortic balloon pump was placed for hemodynamic support along with continued inotropic support. Patient had a good clinical recovery. 3. Discussion SF represents an important clinical entity which is most likely underestimated. Clinical presentation ranges from an incidental finding in an asymptomatic patient to a presentation of recurrent angina, MI, and even sudden death. The majority of studies report the incidence of SF between 1 and 8% Stent fracture current classification
Fig. 3. (A) Stent boost showing displaced fragments of the previous proximal LAD stent. (B) Long stent bridging the two fragments of the broken stent.
Please cite this article in press as: V. Nivargi, et al., Mending the broken stent, J Indian Coll Cardiol. (2017), http://dx.doi.org/10.1016/j. jicc.2017.08.003
G Model JICC 431 No. of Pages 3
V. Nivargi et al. / Journal of Indian College of Cardiology xxx (2017) xxx–xxx
3
laboratory allow improved visibility of stent struts and detection of stent fracture. 5. Management
Fig. 4. Coronary angiogram showing the final result after deploying two stents in the LAD.
This patient had a type IV stent fracture. Consequences of stent fracture include in-stent restenosis, stent thrombosis, coronary aneurysm, or sudden cardiac death. Stent fracture has been associated with excessive tortuosity or angulation of vessels, right coronary artery stents, overlapping stents, and long stents.4 Additional technical factors include inappropriate handling, high-pressure deployment, stenting in calcified segments, and manufacturing flaws, including use of stents with greater predisposition to stent fracture. 4. Diagnostic modalities There is no consensus on the best diagnostic imaging modality for detection of SFs, but it is well recognized that conventional angiography is not sufficiently sensitive for this purpose. Multiple imaging modalities can be used, including IVUS, stent boost, Multidetector Computed Tomography, and Optimal Coherence Tomography (OCT). In our case IVUS and stent boost came to the rescue. Stent visibility is limited on conventional fluoroscopic imaging, further decreased by patient body habitus, stent platform, and stent thickness. Earlier generation stainless-steel stents had a strut thickness of up to 0.0055 in., yielding good fluoroscopic visibility compared to newer generation cobalt–chromium. Stents with strut thickness as low as 0.0032 in., which reduces fluoroscopic visibility.5 However, technological advances in software for acquisition of enhanced images in the catheterization
There is no consensus about the ideal management of SFs. The decision should depend on the type of fracture, presence of ischemia, and the presence of factors that predict possible recurrence. If the reason of SF was stent overexpansion, then restenting the lesion again is possible with avoidance of stent overexpansion. On the other hand, when SF is caused by a non-modifiable factor like excessive vessel tortuosity, then referring the patient for coronary artery bypass grafting is more reasonable when there is a clear need for revascularization. Khanna et al. reported a case of acute STEMI 6 years after implantation of a sirolimus-eluting stent, secondary to complete SF, which was treated with CABG because of the expected recurrence of SF.6 In a study by Lee7 1009 patients with DES underwent a followup coronary angiography irrespective of symptoms. Seventeen SFs were detected in 15 patients (1.5%). All SF patients were continued on medication with combination antiplatelet therapy, regardless of angina symptoms. If in-stent restenosis at the fractured site was significant, coronary interventions were performed even in patients without ischemic symptoms. Some patients were treated with heterogeneous DES for restenosis lesions (5/8 patients) and the rest were treated with either homogenous DES (2 patients), or plain balloon angioplasty (1 patient) or medical treatment only (7 patients). An important tip in the management of SF by restenting, when there is difficulty in passing the wire or balloon across the lesion, is to use stent boost guidance to manipulate the wire and balloon across the lesion. This case demonstrates the most severe presentation of a DES fracture, with sudden coronary thrombosis and subsequent myocardial infarction, which was diagnosed angiographically with the help of stent boost and treated early and effectively. Conflict of interest statement The authors have none to declare. References 1. 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;71:614–618 [PubMed]. 2. Sianos G, Hofma S, Ligthart JM, et al. Stent fracture and restenosis in the drugeluting stent era. Catheter Cardiovasc Interv. 2004;61:111–116 [PubMed]. 4. Canan T, Lee MS. Drug-eluting stent fracture: incidence, contributing factors, and clinical implications. Catheter Cardiovasc Interv. 2010;75(2):237–245. 5. Ramegowda RT, Chikkaswamy SB, Bharatha A, et al. Circumferential stent fracture. Novel detection and treatment with the use of stent boost. Tex Heart Inst J. 2012;39:431–434 [PMC free article][PubMed]. 6. Khanna R, Kapoor A, Sinha N. Acute ST-elevation myocardial infarction 6 years following a sirolimus-eluting stent secondary to complete stent fracture. J Invasive Cardiol. 2012;24:E64–E66 [PubMed]. 7. Lee SE, Jeong MH, Kim IS, et al. Clinical outcomes and optimal treatment for stent fracture after drug-eluting stent implantation. J Cardiol. 2009;53:422–428 [PubMed].
Further reading Alexopoulos D, Xanthopoulou I. Coronary stent fracture: how frequent it is? Does it matter?. Hellenic J Cardiol. 2011; 52: 1-5 [PubMed].
Please cite this article in press as: V. Nivargi, et al., Mending the broken stent, J Indian Coll Cardiol. (2017), http://dx.doi.org/10.1016/j. jicc.2017.08.003
Journal of Indian College of Cardiology xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Indian College of Cardiology journal homepage: www.elsevier.com/locate/jicc
Case report
Mending the broken stent Varun Nivargia , C.N. Makhaleb , M.S. Hiremathc a
Cardiology Consultancy, Ruby Hall Clinic, Pune, India Cardiology, Ruby Hall Clinic, Pune, India c Cardiology Consultancy, Ruby Hall Clinic Pune, CSI President India, Pune, India b
A R T I C L E I N F O
Article history: Received 17 January 2017 Accepted 28 August 2017 Available online xxx Keywords: Stent fracture IVUS
A B S T R A C T
A 54-year-old male patient diabetic with history of coronary angioplasty 4 years back with a drug eluting stent presented with anterior wall ST segment Elevation Myocardial Infarction. He was taken up for primary angioplasty, diagnostic angiogram showed 100% thrombotic occlusion of proximal left anterior descending artery with an aneurysm. A stent boost was done which showed a fragmented left anterior descending artery stent with disarticulation of both fragments. Two drug eluting stents one in proximal left anterior descending artery bridging the broken fragments of the previous stent and other in a mid left anterior descending artery lesion of 90% were deployed with excellent angiographic outcome with TIMI III flow. © 2017 Indian College of Cardiology. All rights reserved.
1. Introduction A dramatic revolution in the field of intervention cardiology has been heralded by the use drug-eluting stents (DES) replacing bare metal stents (BMS), and thereby significantly reducing the restenosis rates and the need for repeat revascularization.1 However, the occurrence of late-onset complications, such as stent thrombosis, has raised concern over the use of DES. In addition, there has been an increasing awareness of stent fracture (SF) as a potential complication following DES implantation. Review of the literature shows there is increasing concern about SF as a potential cause of stent restenosis and thrombosis, which can lead to adverse clinical outcomes such as recurrent angina, myocardial infarction (MI), and even sudden death. Coronary SF was first reported in 2002 after a BMS implantation in a venous bypass graft. The first case of coronary DES fracture appeared in 20042 after which several cases of SFs were reported
therapy aspirin 100 mg presented with acute onset chest pain Canadian Classification System grade 4 and New York Heart Association class 4 dyspnoea. Time since onset of symptoms to hospital admission was 90 min. 12 lead electrocardiogram was suggestive of acute Anterior wall ST Elevation Myocardial Infarction. His vitals included heart rate of 108 beats/min sinus rhythm, blood pressure of 80/60 mmHg, respiratory rate of 34 per min with cold extremities. His chest had extensive crepitation's bilaterally . Thus he was in cardiogenic shock. He was on dual inotropic support and non-invasive ventilation. Decision for primary angioplasty was taken with the consent of the relatives. Patient was treated with loading dose of ticagrelor (90 mg two tablets of ticagrelor), 350 mg of aspirin non enteric coated, 80 mg of atorvastatin. 2.1. Course in Cath Lab
2. Case A 54-year-old male patient with history of type 2 diabetes mellitus on oral hypoglycaemic agents and history of angioplasty to left anterior descending artery (LAD) with drug eluting stent (details not known) 4 years back presently on single antiplatelet
He was taken up for primary percutaneous intervention (PCI). Right femoral approach was used. Adequate heparinization was done and patient was started on tirofiban infusion after the initial bolus dose. Diagnostic angiogram showed 100% thrombotic occlusion of proximal left anterior descending artery with an aneurysm (Figs. 1 and 2). Floppy Guide wire was initially thought to have crossed in to the distal LAD, but there was difficulty in
http://dx.doi.org/10.1016/j.jicc.2017.08.003 1561-8811/© 2017 Indian College of Cardiology. All rights reserved.
Please cite this article in press as: V. Nivargi, et al., Mending the broken stent, J Indian Coll Cardiol. (2017), http://dx.doi.org/10.1016/j. jicc.2017.08.003
G Model JICC 431 No. of Pages 3
2
V. Nivargi et al. / Journal of Indian College of Cardiology xxx (2017) xxx–xxx
Fig. 1. Diagnostic coronary angiogram showing proximal LAD total thrombotic occlusion.
crossing the balloon. The aneurysm and thrombus was compounding the problem. Hence a stent boost was done which showed a fragmented LAD stent with disarticulation and displacement of both fragments (type IV stent fracture) (Fig. 3A). The wiring was very challenging as we had to cross through the true lumens of both the stent fragments. We used extra floppy, whisper, cross 100, Gaia II along with help of micro catheter but wire could not be negotiated through lumen of both fragments .All efforts were in vain. Presence of aneurysm, thrombus and dynamic movements of two fragments were complicating the issue. Intravascular ultrasound (IVUS) was advanced over one wire which showed true lumen and false lumen as well as angulations of two fragmented segments. Another buddy wire Gaia II was advanced by the side of IVUS and concurrently using IVUS as well as fluoroscopic image the guide wire was negotiated into the true lumen of Distal fragment. Second guide wire now acted as the primary wire. The entire stent was restudied with IVUS on primary wire. After this thrombus suction and graded balloon dilatation was done. Then two Everolimus drug eluting stents 3.5–48 in proximal LAD bridging the broken fragments of the previous stent (Fig. 3B) and another Everolimus
Fig. 2. Coronary angiogram showing the proximal LAD aneurysm.
eluting stent 3–18 in a mid LAD lesion of 90% were deployed with excellent angiographic outcome with TIMI III flow (Fig. 4). Adequate pre dilatation and post dilatation was done. Intracoronary adenosine, nicorandil was also given. Thus the old fragmented stent was bridged with a long stent. Owing to the poor hemodynamic of the patient he was electively intubated for mechanical ventilation and intra aortic balloon pump was placed for hemodynamic support along with continued inotropic support. Patient had a good clinical recovery. 3. Discussion SF represents an important clinical entity which is most likely underestimated. Clinical presentation ranges from an incidental finding in an asymptomatic patient to a presentation of recurrent angina, MI, and even sudden death. The majority of studies report the incidence of SF between 1 and 8% Stent fracture current classification
Fig. 3. (A) Stent boost showing displaced fragments of the previous proximal LAD stent. (B) Long stent bridging the two fragments of the broken stent.
Please cite this article in press as: V. Nivargi, et al., Mending the broken stent, J Indian Coll Cardiol. (2017), http://dx.doi.org/10.1016/j. jicc.2017.08.003
G Model JICC 431 No. of Pages 3
V. Nivargi et al. / Journal of Indian College of Cardiology xxx (2017) xxx–xxx
3
laboratory allow improved visibility of stent struts and detection of stent fracture. 5. Management
Fig. 4. Coronary angiogram showing the final result after deploying two stents in the LAD.
This patient had a type IV stent fracture. Consequences of stent fracture include in-stent restenosis, stent thrombosis, coronary aneurysm, or sudden cardiac death. Stent fracture has been associated with excessive tortuosity or angulation of vessels, right coronary artery stents, overlapping stents, and long stents.4 Additional technical factors include inappropriate handling, high-pressure deployment, stenting in calcified segments, and manufacturing flaws, including use of stents with greater predisposition to stent fracture. 4. Diagnostic modalities There is no consensus on the best diagnostic imaging modality for detection of SFs, but it is well recognized that conventional angiography is not sufficiently sensitive for this purpose. Multiple imaging modalities can be used, including IVUS, stent boost, Multidetector Computed Tomography, and Optimal Coherence Tomography (OCT). In our case IVUS and stent boost came to the rescue. Stent visibility is limited on conventional fluoroscopic imaging, further decreased by patient body habitus, stent platform, and stent thickness. Earlier generation stainless-steel stents had a strut thickness of up to 0.0055 in., yielding good fluoroscopic visibility compared to newer generation cobalt–chromium. Stents with strut thickness as low as 0.0032 in., which reduces fluoroscopic visibility.5 However, technological advances in software for acquisition of enhanced images in the catheterization
There is no consensus about the ideal management of SFs. The decision should depend on the type of fracture, presence of ischemia, and the presence of factors that predict possible recurrence. If the reason of SF was stent overexpansion, then restenting the lesion again is possible with avoidance of stent overexpansion. On the other hand, when SF is caused by a non-modifiable factor like excessive vessel tortuosity, then referring the patient for coronary artery bypass grafting is more reasonable when there is a clear need for revascularization. Khanna et al. reported a case of acute STEMI 6 years after implantation of a sirolimus-eluting stent, secondary to complete SF, which was treated with CABG because of the expected recurrence of SF.6 In a study by Lee7 1009 patients with DES underwent a followup coronary angiography irrespective of symptoms. Seventeen SFs were detected in 15 patients (1.5%). All SF patients were continued on medication with combination antiplatelet therapy, regardless of angina symptoms. If in-stent restenosis at the fractured site was significant, coronary interventions were performed even in patients without ischemic symptoms. Some patients were treated with heterogeneous DES for restenosis lesions (5/8 patients) and the rest were treated with either homogenous DES (2 patients), or plain balloon angioplasty (1 patient) or medical treatment only (7 patients). An important tip in the management of SF by restenting, when there is difficulty in passing the wire or balloon across the lesion, is to use stent boost guidance to manipulate the wire and balloon across the lesion. This case demonstrates the most severe presentation of a DES fracture, with sudden coronary thrombosis and subsequent myocardial infarction, which was diagnosed angiographically with the help of stent boost and treated early and effectively. Conflict of interest statement The authors have none to declare. References 1. 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;71:614–618 [PubMed]. 2. Sianos G, Hofma S, Ligthart JM, et al. Stent fracture and restenosis in the drugeluting stent era. Catheter Cardiovasc Interv. 2004;61:111–116 [PubMed]. 4. Canan T, Lee MS. Drug-eluting stent fracture: incidence, contributing factors, and clinical implications. Catheter Cardiovasc Interv. 2010;75(2):237–245. 5. Ramegowda RT, Chikkaswamy SB, Bharatha A, et al. Circumferential stent fracture. Novel detection and treatment with the use of stent boost. Tex Heart Inst J. 2012;39:431–434 [PMC free article][PubMed]. 6. Khanna R, Kapoor A, Sinha N. Acute ST-elevation myocardial infarction 6 years following a sirolimus-eluting stent secondary to complete stent fracture. J Invasive Cardiol. 2012;24:E64–E66 [PubMed]. 7. Lee SE, Jeong MH, Kim IS, et al. Clinical outcomes and optimal treatment for stent fracture after drug-eluting stent implantation. J Cardiol. 2009;53:422–428 [PubMed].
Further reading Alexopoulos D, Xanthopoulou I. Coronary stent fracture: how frequent it is? Does it matter?. Hellenic J Cardiol. 2011; 52: 1-5 [PubMed].
Please cite this article in press as: V. Nivargi, et al., Mending the broken stent, J Indian Coll Cardiol. (2017), http://dx.doi.org/10.1016/j. jicc.2017.08.003