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Very late acquired peri-stent contrast staining and incomplete stent apposition with biodegradable polymer stents: Insight from optical coherence tomography
International Journal of Cardiology 176 (2014) e11–e12
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Very late acquired peri-stent contrast staining and incomplete stent apposition with biodegradable polymer stents: Insight from optical coherence tomography Hiroaki Takashima ⁎, Shinichiro Sakurai, Katsuhisa Waseda, Akiyoshi Kurita, Hirohiko Ando, Soichiro Kumagai, Tetsuya Amano Department of Cardiology, Aichi Medical University, Japan
a r t i c l e
i n f o
Article history: Received 2 May 2014 Accepted 29 June 2014 Available online 23 July 2014 Keywords: Peri-stent contrast staining Incomplete stent apposition Optical coherence tomography Biodegradable polymer Drug eluting stent
A 68-year-old female with hypertension, dyslipidemia, and impaired glucose tolerance had undergone percutaneous coronary intervention to the left anterior descending artery (LAD) because of exertion angina pectoris in July 2012. At that procedure, severe intramural hematoma had occurred from the proximal to the distal segment of LAD. Therefore, she had been implanted with three biolimus-eluting stents after ballooning at the proximal to distal LAD (Fig. 1A). After then, she had been relieved from angina symptom. The mid-term follow-up coronary angiography showed good patency without in-stent restenosis at 9 months after the procedure (Fig. 1B). In February 2014, she complained mild exertion angina symptom, and her stress myocardial perfusion image assigned inducible anterior myocardial ischemia. Coronary angiography showed type II pattern of in-stent restenosis (ISR) at
⁎ Corresponding author at: Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195, Japan. Tel.: +81 561 62 3311; fax: +81 561 63 8482. E-mail address: [email protected] (H. Takashima).
http://dx.doi.org/10.1016/j.ijcard.2014.06.101 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
the proximal site of stent fracture in the middle of LAD, and multiple peri-stent contrast staining (PSS) in stented segment of LAD (Fig. 1C). Optical coherence tomography images identified multiple peri-stent ulcer-like appearance and incomplete stent apposition (ISA) over the entire stented segment (Fig. 2 and Movie 1). In 1st generation drug-eluting stents, we have recognized that the incidence of PSS was the cause of hypersensitivity reaction to vascular wall with durable polymer (1). However, we confirmed a rare case of the PSS and ISA which was observed in the biolimus-eluting stent coated with biodegradable polymer more than 1 year after the stent implantation. While pathophysiological data were lacking in this case, Angiography and OCT images helped us to identify the different mechanisms of PSS or ISA during drug-eluting stent implantation. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.06.101.
Acknowledgment The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
Reference [1] Kon H, Sakai H, Otsubo M, et al. Contrast staining outside the sirolimus-eluting stent leading to coronary aneurysm formation: a case of very late stent thrombosis associated with hypersensitivity reaction. Circ Cardiovasc Interv 2011;4:e1–3.
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H. Takashima et al. / International Journal of Cardiology 176 (2014) e11–e12
Fig. 1. Coronary angiography (CAG) findings of left anterior descending after biolimus-eluting stent implantation. A: Initial percutaneous coronary intervention (PCI). Dashed line indicates stented segment. B: CAG at 9 month after PCI. CAG showed no evidence of peri-stent contrast staining (PSS). C: CAG at 19 months after PCI. CAG showed PSS (white arrow) at the middle of LAD.
Fig. 2. Optical coherence tomography (OCT) findings 19 months after biolimus-eluting stent implantation. A and B: OCT showed incomplete stent apposition (ISA) at proximal site. C: The image of ISA detected by OCT which showed PSS detected by CAG. D: OCT showed well-apposed stent struts. E: OCT showed peri-stent ulcer-like appearance at distal site.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Very late acquired peri-stent contrast staining and incomplete stent apposition with biodegradable polymer stents: Insight from optical coherence tomography Hiroaki Takashima ⁎, Shinichiro Sakurai, Katsuhisa Waseda, Akiyoshi Kurita, Hirohiko Ando, Soichiro Kumagai, Tetsuya Amano Department of Cardiology, Aichi Medical University, Japan
a r t i c l e
i n f o
Article history: Received 2 May 2014 Accepted 29 June 2014 Available online 23 July 2014 Keywords: Peri-stent contrast staining Incomplete stent apposition Optical coherence tomography Biodegradable polymer Drug eluting stent
A 68-year-old female with hypertension, dyslipidemia, and impaired glucose tolerance had undergone percutaneous coronary intervention to the left anterior descending artery (LAD) because of exertion angina pectoris in July 2012. At that procedure, severe intramural hematoma had occurred from the proximal to the distal segment of LAD. Therefore, she had been implanted with three biolimus-eluting stents after ballooning at the proximal to distal LAD (Fig. 1A). After then, she had been relieved from angina symptom. The mid-term follow-up coronary angiography showed good patency without in-stent restenosis at 9 months after the procedure (Fig. 1B). In February 2014, she complained mild exertion angina symptom, and her stress myocardial perfusion image assigned inducible anterior myocardial ischemia. Coronary angiography showed type II pattern of in-stent restenosis (ISR) at
⁎ Corresponding author at: Department of Cardiology, Aichi Medical University, 1-1 Yazakokarimata, Nagakute, Aichi 480-1195, Japan. Tel.: +81 561 62 3311; fax: +81 561 63 8482. E-mail address: [email protected] (H. Takashima).
http://dx.doi.org/10.1016/j.ijcard.2014.06.101 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
the proximal site of stent fracture in the middle of LAD, and multiple peri-stent contrast staining (PSS) in stented segment of LAD (Fig. 1C). Optical coherence tomography images identified multiple peri-stent ulcer-like appearance and incomplete stent apposition (ISA) over the entire stented segment (Fig. 2 and Movie 1). In 1st generation drug-eluting stents, we have recognized that the incidence of PSS was the cause of hypersensitivity reaction to vascular wall with durable polymer (1). However, we confirmed a rare case of the PSS and ISA which was observed in the biolimus-eluting stent coated with biodegradable polymer more than 1 year after the stent implantation. While pathophysiological data were lacking in this case, Angiography and OCT images helped us to identify the different mechanisms of PSS or ISA during drug-eluting stent implantation. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.06.101.
Acknowledgment The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.
Reference [1] Kon H, Sakai H, Otsubo M, et al. Contrast staining outside the sirolimus-eluting stent leading to coronary aneurysm formation: a case of very late stent thrombosis associated with hypersensitivity reaction. Circ Cardiovasc Interv 2011;4:e1–3.
e12
H. Takashima et al. / International Journal of Cardiology 176 (2014) e11–e12
Fig. 1. Coronary angiography (CAG) findings of left anterior descending after biolimus-eluting stent implantation. A: Initial percutaneous coronary intervention (PCI). Dashed line indicates stented segment. B: CAG at 9 month after PCI. CAG showed no evidence of peri-stent contrast staining (PSS). C: CAG at 19 months after PCI. CAG showed PSS (white arrow) at the middle of LAD.
Fig. 2. Optical coherence tomography (OCT) findings 19 months after biolimus-eluting stent implantation. A and B: OCT showed incomplete stent apposition (ISA) at proximal site. C: The image of ISA detected by OCT which showed PSS detected by CAG. D: OCT showed well-apposed stent struts. E: OCT showed peri-stent ulcer-like appearance at distal site.