Canadian Journal of Cardiology 31 (2015) 691.e1e691.e3 www.onlinecjc.ca
Case Report
Managing Bioabsorbable Vascular Scaffold Failure: Combined Scaffold Restenosis and Late-Acquired Coronary Aneurysm Treated With Self-Expandable Stent Alessio La Manna, MD, Andrea Mangiameli, MD, Davide Capodanno, MD, PhD, Giovanni Longo, MD, Carmelo Sgroi, MD, and Corrado Tamburino, MD, PhD Ferrarotto Hospital, University of Catania, Catania, Italy
ABSTRACT
RESUM E
A 50-year-old man underwent coronary angiography for stable angina with evidence of chronic total occlusion of the right coronary artery. Chronic total occlusion recanalization was performed with implantation of 4 overlapping bioresorbable vascular scaffolds. At 12 months, elective follow-up coronary angiography documented an asymptomatic 90% in-scaffold restenosis of the right coronary artery located in the mid portion of a newly late-acquired aneurysm. To address the challenging issue introduced by the varying reference vessel diameters, a self-expandable stent was implanted.
Un homme de 50 ans a subi une coronarographie pour une angine stable montrant une occlusion totale chronique de l’artère coronaire te re alise e droite. La recanalisation de l’occlusion totale chronique a e au moyen de l’implantation de 4 endoprothèses vasculaires biosorbables qui se chevauchent. À 12 mois, la coronarographie de re montre une reste nose intrastent de 90 % asymptomatique suivi a de e dans la partie moyenne d’un de l’artère coronaire droite situe vrisme acquis re cemment. Pour re gler le problème complexe que ane sentent les diffe rents diamètres vasculaires de re fe rence, une repre te implante e. endoprothèse auto-extensible a e
A 50-year-old man underwent coronary angiography for stable angina with evidence of ischemia documented with a stress test. Coronary angiography showed a 70% stenosis of the left anterior descendent artery, treated with drug-eluting stent implantation, and a chronic total occlusion of the right coronary artery (RCA). After subsequent demonstration of viability of the RCA myocardium territory using cardiac magnetic resonance, chronic total occlusion recanalization was undertaken with an antegrade approach using a single-wire technique. A low-profile coronary balloon 1.5/20 mm (Emerge; Boston Scientific, Maple Groove, MN) was first used to perform multiple inflations from the distal to the proximal segment of the lesion. Then, a 2.5/40 mm balloon (Conic; Conic Vascular Technology, Lugano, Switzerland) was used to perform further lesion preparation. Finally a “full polymer jacket” treatment with 4 overlapping bioresorbable vascular scaffolds (BVS) (Abbott Vascular, Santa Clara, CA) was performed (2.5 28, 3.0 18, 3.5 28, and 3.5 28 mm from distal to proximal, respectively), with optimal expansion and apposition in optical coherence tomography (OCT) (St Jude Medical, Inc, St Paul,
MN). At 12 months, elective follow-up coronary angiography documented an asymptomatic 90% in-scaffold restenosis of the RCA located in the mid portion of a newly acquired aneurysmatic segment. OCT (Fig. 1) confirmed the severity of the restenosis (the minimal lumen area was 0.8 mm2 and the mean lumen diameter was 0.89 mm), due to neointimal thickening with high backscatter. In the remaining aneurysmatic segment the neointimal layer was thinner, with more attenuated backscatter, a maximal lumen area of 22.19 mm2 and a mean lumen diameter of 5.29 mm. Some cross-sections showed evidence of late-acquired incomplete scaffold apposition. The extremely different calipers of the coronary vessel segments hampered a conventional management with balloonexpandable stents. This led to the implantation of a drugeluting self-expandable stent 3.5-4.5/27 mm (Stentys, Paris, France) after predilatation with a 3.0/20 mm semicompliant balloon. Postdilatation was performed with a 4.0/20 mm balloon to ensure complete stent expansion. Final angiography showed a good result with no residual stenosis. The final OCT pullback showed complete stent apposition in the proximal segment, with a lumen area of 10.7 mm2 and a mean lumen diameter of 3.68 mm. In the distal part of the stent there was a mild incomplete stent apposition inside the aneurysmatic segment, with maximal stent-to-wall distance of 0.2 mm for a maximal length of 1 mm. No further action was undertaken. The true incidence of late-acquired coronary artery aneurysms after drug-eluting stent implantation is unclear. Data
Received for publication November 19, 2014. Accepted December 17, 2014. Corresponding author: Dr Andrea Mangiameli, Cardiology Department, Ferrarotto Hospital, University of Catania, Via Citelli 6, 95124 Catania, Italy. Tel.: þ39-0957436202; fax: þ39-095362429. E-mail: [email protected] See page 691.e3 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2014.12.021 0828-282X/Ó 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
691.e2
Canadian Journal of Cardiology Volume 31 2015
Figure 1. (A) Emergent angiography with chronic total occlusion of the proximal right coronary artery. (B) Angiographic result after Absorb (Abbott Vascular, Santa Clara, CA) implantation. (C) Coronary angiography at 12 months, showing critical in-scaffold restenosis located in the mid portion of a newly acquired ectatic trait. (D) Final angiographic result after self-expandable stent implantation. (a, f) Optical coherence tomography cross-sections at 12 months showing normal vessel with optimal scaffold apposition. (b, c) Ectatic trait with scaffold struts embedded in the aneurysmal vessel wall (b) and incomplete scaffold apposition with scaffold struts floating in the vessel lumen (c). (d, e) Neointimal thickening with layered pattern and high backscatter responsible for restenosis. A double-struts layer can be clearly identified at the overlap site (E). (g) Longitudinal reconstruction showing the aneurysm and the restenosis area (a’), absence of dissection at the distal edge of the stent. (b’, c’) Ectatic trait covered by the self-expanding stent, the maximal strut-towall distance being approximately 0.2 mm (F). (d’, e’) Final result at the level of the previous restenosis. (g’) Longitudinal view after implantation of the self-expanding stent.
from early first-generation drug-eluting stent trials reported on a very low incidence of aneurysm formation at 8-month follow-up, in the range of 0.2% to 2.3% in the sirolimuseluting stent arm.1 BVS represent a relatively recent technology; hence the actual incidence of coronary artery aneurysm is even more obscure.
However, case reports of late-acquired coronary artery aneurysms after BVS implantation have been recently reported.2 This case documents that positive remodelling and restenosis might coexist in the same vessel in a patient treated with BVS. The aetiology of aneurysm formation is unclear, and possibly multifactorial, with extreme positive vessel remodelling a
La Manna et al. Management of Unusual In-Scaffold Restenosis
possible cause.3 In our case, the restenosis occurred at the site of an overlapping point. Overlaps are often associated with an amplified neointimal reaction, thicker than in the nonoverlapping segments,4 which might contribute to explain the coexistence of the aneurysm and the restenosis in the same vessel. Ultimately, management of BVS restenosis represents a challenging scenario, because of the loss of integrity of the BVS struts, which was an already ongoing process at 12 months.5 Placement of another metallic stent therefore seems an appropriate solution to avoid strut dislodgement. To address the additional issue introduced by the varying reference vessel diameters (proximal and distal), a self-expandable stent was implanted because of its ability to adapt to the vessel diameter and provide optimal strut apposition even in ectatic vessels or coronary aneurysms. Disclosures Dr Tamburino has received speaker’s honoraria from Abbott Vascular. All other authors have no relationships relevant to the contents of this paper to disclose.
691.e3
References 1. Aoki J, Kirtane A, Leon MB, Dangas G. Coronary artery aneurysms after drug-eluting stent implantation. JACC Cardiovasc Interv 2008;1: 14-21. 2. Garciulo G, Mangiameli A, Capodanno D, et al. Newly onset coronary aneurism and late-acquired incomplete scaffold apposition after full polymer jacket of a chronic total occlusion with bioresorbable scaffolds. JACC Cardiovasc Interv 2015 Mar;8:e41-3. 3. Mintz GS. What to do about late incomplete stent apposition? Circulation 2007;115:2379-81. 4. Finn AV, Kolodgie FD, Harnek JM, et al. Differential response of delayed healing and persistent inflammation at sites of overlapping sirolimus- or paclitaxel-eluting stents. Circulation 2005;112: 270-8. 5. Ohno Y, Mangiameli A, Attizzani G, Capodanno D, Tamburino C. Optical coherence tomography assessment of late intra-scaffold dissection: a new challenge of bioresorbable scaffolds. JACC Cardiovasc Interv 2015;8:e11-2.
Case Report
Managing Bioabsorbable Vascular Scaffold Failure: Combined Scaffold Restenosis and Late-Acquired Coronary Aneurysm Treated With Self-Expandable Stent Alessio La Manna, MD, Andrea Mangiameli, MD, Davide Capodanno, MD, PhD, Giovanni Longo, MD, Carmelo Sgroi, MD, and Corrado Tamburino, MD, PhD Ferrarotto Hospital, University of Catania, Catania, Italy
ABSTRACT
RESUM E
A 50-year-old man underwent coronary angiography for stable angina with evidence of chronic total occlusion of the right coronary artery. Chronic total occlusion recanalization was performed with implantation of 4 overlapping bioresorbable vascular scaffolds. At 12 months, elective follow-up coronary angiography documented an asymptomatic 90% in-scaffold restenosis of the right coronary artery located in the mid portion of a newly late-acquired aneurysm. To address the challenging issue introduced by the varying reference vessel diameters, a self-expandable stent was implanted.
Un homme de 50 ans a subi une coronarographie pour une angine stable montrant une occlusion totale chronique de l’artère coronaire te re alise e droite. La recanalisation de l’occlusion totale chronique a e au moyen de l’implantation de 4 endoprothèses vasculaires biosorbables qui se chevauchent. À 12 mois, la coronarographie de re montre une reste nose intrastent de 90 % asymptomatique suivi a de e dans la partie moyenne d’un de l’artère coronaire droite situe vrisme acquis re cemment. Pour re gler le problème complexe que ane sentent les diffe rents diamètres vasculaires de re fe rence, une repre te implante e. endoprothèse auto-extensible a e
A 50-year-old man underwent coronary angiography for stable angina with evidence of ischemia documented with a stress test. Coronary angiography showed a 70% stenosis of the left anterior descendent artery, treated with drug-eluting stent implantation, and a chronic total occlusion of the right coronary artery (RCA). After subsequent demonstration of viability of the RCA myocardium territory using cardiac magnetic resonance, chronic total occlusion recanalization was undertaken with an antegrade approach using a single-wire technique. A low-profile coronary balloon 1.5/20 mm (Emerge; Boston Scientific, Maple Groove, MN) was first used to perform multiple inflations from the distal to the proximal segment of the lesion. Then, a 2.5/40 mm balloon (Conic; Conic Vascular Technology, Lugano, Switzerland) was used to perform further lesion preparation. Finally a “full polymer jacket” treatment with 4 overlapping bioresorbable vascular scaffolds (BVS) (Abbott Vascular, Santa Clara, CA) was performed (2.5 28, 3.0 18, 3.5 28, and 3.5 28 mm from distal to proximal, respectively), with optimal expansion and apposition in optical coherence tomography (OCT) (St Jude Medical, Inc, St Paul,
MN). At 12 months, elective follow-up coronary angiography documented an asymptomatic 90% in-scaffold restenosis of the RCA located in the mid portion of a newly acquired aneurysmatic segment. OCT (Fig. 1) confirmed the severity of the restenosis (the minimal lumen area was 0.8 mm2 and the mean lumen diameter was 0.89 mm), due to neointimal thickening with high backscatter. In the remaining aneurysmatic segment the neointimal layer was thinner, with more attenuated backscatter, a maximal lumen area of 22.19 mm2 and a mean lumen diameter of 5.29 mm. Some cross-sections showed evidence of late-acquired incomplete scaffold apposition. The extremely different calipers of the coronary vessel segments hampered a conventional management with balloonexpandable stents. This led to the implantation of a drugeluting self-expandable stent 3.5-4.5/27 mm (Stentys, Paris, France) after predilatation with a 3.0/20 mm semicompliant balloon. Postdilatation was performed with a 4.0/20 mm balloon to ensure complete stent expansion. Final angiography showed a good result with no residual stenosis. The final OCT pullback showed complete stent apposition in the proximal segment, with a lumen area of 10.7 mm2 and a mean lumen diameter of 3.68 mm. In the distal part of the stent there was a mild incomplete stent apposition inside the aneurysmatic segment, with maximal stent-to-wall distance of 0.2 mm for a maximal length of 1 mm. No further action was undertaken. The true incidence of late-acquired coronary artery aneurysms after drug-eluting stent implantation is unclear. Data
Received for publication November 19, 2014. Accepted December 17, 2014. Corresponding author: Dr Andrea Mangiameli, Cardiology Department, Ferrarotto Hospital, University of Catania, Via Citelli 6, 95124 Catania, Italy. Tel.: þ39-0957436202; fax: þ39-095362429. E-mail: [email protected] See page 691.e3 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2014.12.021 0828-282X/Ó 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
691.e2
Canadian Journal of Cardiology Volume 31 2015
Figure 1. (A) Emergent angiography with chronic total occlusion of the proximal right coronary artery. (B) Angiographic result after Absorb (Abbott Vascular, Santa Clara, CA) implantation. (C) Coronary angiography at 12 months, showing critical in-scaffold restenosis located in the mid portion of a newly acquired ectatic trait. (D) Final angiographic result after self-expandable stent implantation. (a, f) Optical coherence tomography cross-sections at 12 months showing normal vessel with optimal scaffold apposition. (b, c) Ectatic trait with scaffold struts embedded in the aneurysmal vessel wall (b) and incomplete scaffold apposition with scaffold struts floating in the vessel lumen (c). (d, e) Neointimal thickening with layered pattern and high backscatter responsible for restenosis. A double-struts layer can be clearly identified at the overlap site (E). (g) Longitudinal reconstruction showing the aneurysm and the restenosis area (a’), absence of dissection at the distal edge of the stent. (b’, c’) Ectatic trait covered by the self-expanding stent, the maximal strut-towall distance being approximately 0.2 mm (F). (d’, e’) Final result at the level of the previous restenosis. (g’) Longitudinal view after implantation of the self-expanding stent.
from early first-generation drug-eluting stent trials reported on a very low incidence of aneurysm formation at 8-month follow-up, in the range of 0.2% to 2.3% in the sirolimuseluting stent arm.1 BVS represent a relatively recent technology; hence the actual incidence of coronary artery aneurysm is even more obscure.
However, case reports of late-acquired coronary artery aneurysms after BVS implantation have been recently reported.2 This case documents that positive remodelling and restenosis might coexist in the same vessel in a patient treated with BVS. The aetiology of aneurysm formation is unclear, and possibly multifactorial, with extreme positive vessel remodelling a
La Manna et al. Management of Unusual In-Scaffold Restenosis
possible cause.3 In our case, the restenosis occurred at the site of an overlapping point. Overlaps are often associated with an amplified neointimal reaction, thicker than in the nonoverlapping segments,4 which might contribute to explain the coexistence of the aneurysm and the restenosis in the same vessel. Ultimately, management of BVS restenosis represents a challenging scenario, because of the loss of integrity of the BVS struts, which was an already ongoing process at 12 months.5 Placement of another metallic stent therefore seems an appropriate solution to avoid strut dislodgement. To address the additional issue introduced by the varying reference vessel diameters (proximal and distal), a self-expandable stent was implanted because of its ability to adapt to the vessel diameter and provide optimal strut apposition even in ectatic vessels or coronary aneurysms. Disclosures Dr Tamburino has received speaker’s honoraria from Abbott Vascular. All other authors have no relationships relevant to the contents of this paper to disclose.
691.e3
References 1. Aoki J, Kirtane A, Leon MB, Dangas G. Coronary artery aneurysms after drug-eluting stent implantation. JACC Cardiovasc Interv 2008;1: 14-21. 2. Garciulo G, Mangiameli A, Capodanno D, et al. Newly onset coronary aneurism and late-acquired incomplete scaffold apposition after full polymer jacket of a chronic total occlusion with bioresorbable scaffolds. JACC Cardiovasc Interv 2015 Mar;8:e41-3. 3. Mintz GS. What to do about late incomplete stent apposition? Circulation 2007;115:2379-81. 4. Finn AV, Kolodgie FD, Harnek JM, et al. Differential response of delayed healing and persistent inflammation at sites of overlapping sirolimus- or paclitaxel-eluting stents. Circulation 2005;112: 270-8. 5. Ohno Y, Mangiameli A, Attizzani G, Capodanno D, Tamburino C. Optical coherence tomography assessment of late intra-scaffold dissection: a new challenge of bioresorbable scaffolds. JACC Cardiovasc Interv 2015;8:e11-2.
