Canadian Journal of Cardiology
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(2015) 1.e1e1.e2 www.onlinecjc.ca
Images in Cardiology
One-Year Coverage by Optical Coherence Tomography of a Bioresorbable Scaffold Neocarina: Is It Safe to Discontinue Dual-Antiplatelet Therapy? Piera Capranzano, MD, Bruno Francaviglia, MD, Claudia Ina Tamburino, MD, Giuseppe Gargiulo, MD, Giovanni Longo, MD, Davide Capodanno, MD, PhD, and Corrado Tamburino, MD, PhD Cardiovascular Department, Ferrarotto Hospital, University of Catania, Catania, Italy
A 66-year-old man underwent elective successful percutaneous coronary intervention: after recanalization of a chronically occluded ostial left anterior descending (LAD) coronary artery, the left main (LM) bifurcation was treated using the Tstenting and protrusion technique with one 3.5/30 mm zotarolimus-eluting stent (ZES) on the LM-LAD and with one 3.5/18 mm everolimus-eluting bioresorbable vascular scaffold (BVS) on the large ramus intermedius. As it is a common practice to discontinue dual-antiplatelet therapy (DAPT) 1 year after BVS implantation, in consideration of the high-risk lesion and the unknown fate of protruding polymeric side-branch struts, 1-year optical coherence tomography (OCT) was performed to assess neointimal coverage. The OCT showed that both BVS and ZES wall struts were well apposed and evenly covered (Fig. 1A). Differently, protruding polymeric struts had heterogeneous coverage, ranging from partially to fully covered struts, and from a thin to very thick tissue bridge over and between the struts (Fig. 1B-I). The lowest measured value of neointimal thickness, found in several floating struts, was 30 mm, which is the minimum cutpoint suggestive of possible coverage, thus leaving some uncertainty.1 The tissue coverage of a neocarina appeared lower at the outer side of the floating BVS (Fig. 1E) and also between the struts farther from the vessel wall (Fig. 1D) and from each other (Fig. 1G). Sporadic and irregular protruding masses, without backscattering, suggestive for organized thrombi (Fig. 1A-C and G), were detected, along with a not negligible Received for publication March 22, 2015. Accepted March 26, 2015. Corresponding author: Dr Piera Capranzano, Cardiovascular Department, Ferrarotto Hospital, University of Catania, Citelli 1, 95124 Catania, Italy. Tel.: þ39-0957436201; fax: þ39-095362429. E-mail: [email protected] See page 1.e1 for disclosure information.
(1.0 mm) discontinuation in the neocarina (Fig. 1J). Based on these findings, DAPT was continued for further 12 months. Although the 6-month coverage of polymeric struts with malapposition or overlying a side branch was reported, the fate of side-branch BVS struts protruding in main vessels remains unknown;1 indeed, factors potentially impacting on neointimal coverage, including flow-dynamic patterns and shear stress, differ between the latter circumstances. This is the first case reporting on the 1-year coverage status of side-branch BVS struts protruding in main vessels. The 1-year OCT demonstrated a tissue neocarina forming over the protruding BVS struts, although the coverage was widely inhomogeneous and perhaps still incomplete in some portions, thus leading to cautious DAPT extension. The illustrated physiological response can help physicians in evaluating the fate of protruding side-branch BVS struts at 1 year, when DAPT is commonly discontinued in clinical practice, suggesting for a DAPT prolongation beyond 1 year in bifurcation treated with a protruding side-branch BVS. Finally, this case warns for an appropriate use of BVS in side branches. Disclosures Corrado Tamburino has received honoraria/lecture fees from Medtronic, Abbott Vascular, and Edwards Lifesciences. The rest of the authors have no conflicts of interest to disclose. Reference 1. Gutierrez-Chico JL, Gijsen F, Regar E, et al. Differences in neointimal thickness between the adluminal and the abluminal sides of malapposed and side-branch struts in a polylactide bioresorbable scaffold: evidence in vivo about the abluminal healing process. JACC Cardiovasc Interv 2012;5:428-35.
http://dx.doi.org/10.1016/j.cjca.2015.03.029 0828-282X/Ó 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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Canadian Journal of Cardiology Volume - 2015
Figure 1. One-year optical coherence tomography appearance of abioresorbable vascular scaffold (BVS) strut neocarina. (A) Complete coverage after the same implantation time of zotarolimus-eluting stent and everolimus-eluting BVS struts, implanted at the same time, at the left main level. (B-G) Cross-sections of the neocarina with inhomogeneous neointimal growth. (H, I) Homogeneous neocarina coverage. (J) Long view with crosssection cuts. The white arrowheads indicate intraluminal masses, suggestive for organized thrombi. In (D) a thickness measurement (30 mm) with uncertain neointimal coverage of floating struts is shown. The red arrow indicates a tissue discontinuation in the neocarina.
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(2015) 1.e1e1.e2 www.onlinecjc.ca
Images in Cardiology
One-Year Coverage by Optical Coherence Tomography of a Bioresorbable Scaffold Neocarina: Is It Safe to Discontinue Dual-Antiplatelet Therapy? Piera Capranzano, MD, Bruno Francaviglia, MD, Claudia Ina Tamburino, MD, Giuseppe Gargiulo, MD, Giovanni Longo, MD, Davide Capodanno, MD, PhD, and Corrado Tamburino, MD, PhD Cardiovascular Department, Ferrarotto Hospital, University of Catania, Catania, Italy
A 66-year-old man underwent elective successful percutaneous coronary intervention: after recanalization of a chronically occluded ostial left anterior descending (LAD) coronary artery, the left main (LM) bifurcation was treated using the Tstenting and protrusion technique with one 3.5/30 mm zotarolimus-eluting stent (ZES) on the LM-LAD and with one 3.5/18 mm everolimus-eluting bioresorbable vascular scaffold (BVS) on the large ramus intermedius. As it is a common practice to discontinue dual-antiplatelet therapy (DAPT) 1 year after BVS implantation, in consideration of the high-risk lesion and the unknown fate of protruding polymeric side-branch struts, 1-year optical coherence tomography (OCT) was performed to assess neointimal coverage. The OCT showed that both BVS and ZES wall struts were well apposed and evenly covered (Fig. 1A). Differently, protruding polymeric struts had heterogeneous coverage, ranging from partially to fully covered struts, and from a thin to very thick tissue bridge over and between the struts (Fig. 1B-I). The lowest measured value of neointimal thickness, found in several floating struts, was 30 mm, which is the minimum cutpoint suggestive of possible coverage, thus leaving some uncertainty.1 The tissue coverage of a neocarina appeared lower at the outer side of the floating BVS (Fig. 1E) and also between the struts farther from the vessel wall (Fig. 1D) and from each other (Fig. 1G). Sporadic and irregular protruding masses, without backscattering, suggestive for organized thrombi (Fig. 1A-C and G), were detected, along with a not negligible Received for publication March 22, 2015. Accepted March 26, 2015. Corresponding author: Dr Piera Capranzano, Cardiovascular Department, Ferrarotto Hospital, University of Catania, Citelli 1, 95124 Catania, Italy. Tel.: þ39-0957436201; fax: þ39-095362429. E-mail: [email protected] See page 1.e1 for disclosure information.
(1.0 mm) discontinuation in the neocarina (Fig. 1J). Based on these findings, DAPT was continued for further 12 months. Although the 6-month coverage of polymeric struts with malapposition or overlying a side branch was reported, the fate of side-branch BVS struts protruding in main vessels remains unknown;1 indeed, factors potentially impacting on neointimal coverage, including flow-dynamic patterns and shear stress, differ between the latter circumstances. This is the first case reporting on the 1-year coverage status of side-branch BVS struts protruding in main vessels. The 1-year OCT demonstrated a tissue neocarina forming over the protruding BVS struts, although the coverage was widely inhomogeneous and perhaps still incomplete in some portions, thus leading to cautious DAPT extension. The illustrated physiological response can help physicians in evaluating the fate of protruding side-branch BVS struts at 1 year, when DAPT is commonly discontinued in clinical practice, suggesting for a DAPT prolongation beyond 1 year in bifurcation treated with a protruding side-branch BVS. Finally, this case warns for an appropriate use of BVS in side branches. Disclosures Corrado Tamburino has received honoraria/lecture fees from Medtronic, Abbott Vascular, and Edwards Lifesciences. The rest of the authors have no conflicts of interest to disclose. Reference 1. Gutierrez-Chico JL, Gijsen F, Regar E, et al. Differences in neointimal thickness between the adluminal and the abluminal sides of malapposed and side-branch struts in a polylactide bioresorbable scaffold: evidence in vivo about the abluminal healing process. JACC Cardiovasc Interv 2012;5:428-35.
http://dx.doi.org/10.1016/j.cjca.2015.03.029 0828-282X/Ó 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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Canadian Journal of Cardiology Volume - 2015
Figure 1. One-year optical coherence tomography appearance of abioresorbable vascular scaffold (BVS) strut neocarina. (A) Complete coverage after the same implantation time of zotarolimus-eluting stent and everolimus-eluting BVS struts, implanted at the same time, at the left main level. (B-G) Cross-sections of the neocarina with inhomogeneous neointimal growth. (H, I) Homogeneous neocarina coverage. (J) Long view with crosssection cuts. The white arrowheads indicate intraluminal masses, suggestive for organized thrombi. In (D) a thickness measurement (30 mm) with uncertain neointimal coverage of floating struts is shown. The red arrow indicates a tissue discontinuation in the neocarina.
