Korean Circ J.  2009 Oct;39(10):439-442. 10.4070/kcj.2009.39.10.439.

Multiple Sequential Complications After Sirolimus-Eluting Stent Implantation: Very Late Stent Thrombosis, Stent Fracture, In-Stent Restenosis, and Peri-Stent Aneurysm

• Seol SH
• Kim DI
• Han YC
• Kim KH
• Kim DK
• Kim YB
• Kim U
• Yang TH
• Kim DK
• Kim DS

• KMID: 2028926
• DOI: http://doi.org/10.4070/kcj.2009.39.10.439

Abstract

A 55-year-old male patient presented with an acute myocardial infarction. A sirolimus-eluting stent (SES) was implanted in the proximal left anterior descending artery (LAD). Eight months later, there was a newly developed distal LAD lesion. An additional SES was implanted. Twenty-eight months after the index procedure of primary coronary intervention, the electrocardiogram showed ST elevation in the precordial leads and an emergency coronary angiogram showed diffuse stent thrombosis (ST) in the proximal LAD. Thirty-four months after the index procedure, coronary angiography showed a large peri-stent coronary aneurysm in the proximal LAD and focal in-stent restenosis (ISR) at the proximal edge of the distal LAD stent. On fluoroscopy, a fracture was noted in the middle part of the distal SES. A zotarolimus- eluting stent (ZES) was deployed and overlapped the restenosis and fracture sites. Forty months after the index procedure, there were no changes in the size of the aneurysm or in the other stent complications including the fracture and restenosis. At present, the patient has remained asymptomatic for eight months.

Keyword

Percutaneous transluminal coronary augioplasty; Drug-eluting stents

MeSH Terms

Aneurysm
Arteries
Coronary Aneurysm
Coronary Angiography
Drug-Eluting Stents
Electrocardiography
Emergencies
Fluoroscopy
Humans
Male
Middle Aged
Myocardial Infarction
Stents
Thrombosis

Figure

• 

  Fig. 1 Coronary angiography shows a stent thrombosis in the proximal left anterior descending artery (arrow) (A), post-balloon angioplasty (B). An intravascular ultrasound shows late stent malapposition (*) (C). Angiography after five days reveals restoration of the normal blood flow (D).

• 

  Fig. 2 Follow-up angiography reveals a large proximal left anterior descending artery aneurysm (arrow) (A) and an intravascular ultrasound shows malapposition of the stent (B).

• 

  Fig. 3 Coronary angiography demonstrates in-stent restenosis (white arrow) (A), while fluoroscopy shows a fractured sirolimus-eluting stent (black arrow) (B).

• 

  Fig. 4 A 64-slice multidetector computed tomogram shows an eccentric coronary aneurysm in the proximal left anterior descending artery (black arrow) (A) and a cracked sirolimus-eluting stent (white arrow) (B).

Reference

1. Morice MC, Serruys PW, Sousa JE, et al. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med. 2002. 346:1773–1780.

2. Stone GW, Ellis SG, Cannon L, et al. Comparison of a polymer-based paclitaxel-eluting stent with a bare metal stent in patients with complex coronary artery disease: a randomized controlled trial. JAMA. 2005. 294:1215–1223.

3. Mauri L, Hsieh WH, Massaro JM, Ho KK, D'Agostino R, Cutlip DE. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med. 2007. 356:1020–1029.

4. Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA. 2005. 293:2126–2130.

5. Grines CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Coll Cardiol. 2007. 49:734–739.

6. Yang TH, Kim DI, Park SG, et al. Clinical characteristics of stent fracture after sirolimus-eluting stent implantation. Int J Cardiol. 2009. 131:212–216.

7. Bae JH, Hyun DW, Kim KY, Yoon HJ, Nakamura S. Drug-eluting stent strut fracture as a cause of restenosis. Korean Circ J. 2005. 35:787–789.

8. Sianos G, Hofma S, Ligthart JM, et al. Stent fracture and restenosis in the drug-eluting stent era. Catheter Cardiovasc Interv. 2004. 61:111–116.

9. Hoffmann R, Mintz GS, Dussaillant GR, et al. Patterns and mechanisms of in-stent restenosis: a serial intravascular ultrasound study. Circulation. 1996. 94:1247–1254.

10. Lee CW, Park SJ. Predictive factors for restenosis after drug-eluting stent implantation. Korean Circ J. 2007. 37:97–102.

11. Kastrati A, Elezi S, Dirschinger J, Hadamitzky M, Neumann FJ, Schomig A. Influence of lesion length on restenosis after coronary stent placement. Am J Cardiol. 1999. 83:1617–1622.

12. Kastrati A, Schomig A, Elezi S, et al. Predictive factors of restenosis after coronary stent placement. J Am Coll Cardiol. 1997. 30:1428–1436.

13. Elezi S, Kastrati A, Neumann FJ, Hadamitzky M, Dirschinger J, Schomig A. Vessel size and long-term outcome after coronary stent placement. Circulation. 1998. 98:1875–1880.

14. Hoffmann R, Mintz GS, Mehran R, et al. Intravascular ultrasound predictors of angiographic restenosis in lesions treated with Palmaz-Schatz stents. J Am Coll Cardiol. 1998. 31:43–49.

15. Slota PA, Fischman DL, Savage MP, Rake R, Goldberg S. Frequency and outcome of development of coronary artery aneurysm after intracoronary stent placement and angioplasty. STRESS Trial Investigators. Am J Cardiol. 1997. 79:1104–1106.

16. Mintz GS, Shah VM, Weissman NJ. Regional remodeling as the cause of late stent malapposition. Circulation. 2003. 107:2660–2663.

17. Virmani R, Guagliumi G, Farb A, et al. Localized hypersensitivity and late coronary thrombosis secondary to a sirolimus-eluting stent: should we be cautious? Circulation. 2004. 109:701–705.

18. Bavry AA, Chiu JH, Jefferson BK, et al. Development of coronary aneurysm after drug-eluting stent implantation. Ann Intern Med. 2007. 146:230–232.

19. Gurvitch R, Yan BP, Warren R, Marasco S, Black AJ, Ajani AE. Spontaneous resolution of multiple coronary aneurysms complicating drug eluting stent implantation. Int J Cardiol. 2008. 130:e7–e10.