CE: Namrta; JCM-D-13-00624; Total nos of Pages: 4;
JCM-D-13-00624
Images in cardiovascular medicine
Optical coherence tomography-guided treatment of very late stent thrombosis caused by inaccurate stent deployment in a bifurcation Francesco De Caro, Marco De Carlo and Anna S. Petronio A 65-year-old man presented at our institution with anterior wall reinfarction, due to very late stent thrombosis, 4 years after primary angioplasty on the first bifurcation of the left anterior descending artery. Using intravascular optical coherence tomography, we identified stent malapposition in the proximal left anterior descending artery, occurring during the first primary angioplasty, as the probable cause of the very late stent thrombosis. Imaging with optical coherence tomography guided our treatment strategy of mechanical and pharmacological thrombectomy, followed by staged stent postdilatation.
J Cardiovasc Med 2014, 15:000–000
In 2009, a 60-year-old man underwent primary angioplasty for anterior myocardial infarction with deployment of two drug-eluting stents, a Cypher 2.5 8 mm (Cordis Corp., Johnson & Johnson, Warren, New Jersey, USA) in the mid left anterior descending artery (LAD), and a Xience V 2.5 28 mm (Abbott Vascular, Santa Clara, California, USA), proximal to the Cypher stent, extending into the bifurcation of the proximal LAD with a large first diagonal branch (Fig. 1). Four years later, the patient presented with anterior wall reinfarction; coronary angiography showed subocclusive thrombosis at the proximal edge of the Xience stent (Fig. 2, arrow), with distal LAD embolization. After successful rheolytic thrombectomy and intracoronary administration of a bolus of abciximab 0.25 mg/kg (Fig. 3), optical coherence tomography (OCT) revealed an abrupt change in the diameter of
the LAD at the transition between the proximal and mid portion (from 3.6 to 2.7 mm), resulting in partial malapposition of the proximal 2 mm of the Xience stent, with scarce residual thrombus on the nonendothelized stent struts (Fig. 4, arrows). The remaining length of the Xience stent was well apposed, adequately expanded, and completely endothelized, with no evidence of thrombus. Immediately after the procedure, the patient received 12-h abciximab 0.125 mg/kg/min intravenous infusion, and prasugrel 60 mg oral loading dose. After 4 days, OCT performed during elective coronary angiography showed complete resolution of thrombosis in the malapposed proximal edge of the Xience stent (Fig. 5), which we decided to postdilate aggressively with a 4 mm noncompliant balloon (Fig. 6) in order to achieve apposition to the vessel wall. We completed the procedure with
Keywords: endothelization, intravascular imaging, optical coherence tomography, stent thrombosis Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, University of Pisa, Pisa, Italy Correspondence to Francesco De Caro, MD, Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Ospedale Cisanello, Via Paradisa 2, 56124 Pisa, Italy Tel: +39 050 995330; fax: +39 050 995325; e-mail: [email protected] Received 19 November 2013 Revised 5 April 2014 Accepted 7 April 2014
Fig. 1
(a)
(b)
(a) Left coronary angiogram during the first primary angioplasty in 2009, showing the subocclusion of the mid left anterior descending artery, just distal to the bifurcation with a large first diagonal branch (arrow). (b) Final result after angioplasty.
1558-2027 ß 2014 Italian Federation of Cardiology
DOI:10.2459/JCM.0000000000000126
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Namrta; JCM-D-13-00624; Total nos of Pages: 4;
JCM-D-13-00624
2 Journal of Cardiovascular Medicine 2014, Vol 00 No 00
Fig. 2
Fig. 4
Zoom: 1.7x 10
20
30
40
mm
2 0
Left coronary angiogram during the second primary angioplasty in 2013, showing the presence of thrombus at the proximal edge of the stent implanted in the mid left anterior descending artery (LAD) (arrow).
deployment of a new Xience V 4.0 8 mm stent, overlapping the first 1.5 mm of the previously implanted Xience stent (Fig. 7). Stent thrombosis is a potentially life-threatening complication of percutaneous coronary intervention. According to the timing of the onset, stent thrombosis is classified as early (differentiated in acute between 0 and 24 h and subacute between 24 h and 30 days after stent implantation), late (>30 days to 1 year after stent implantation), or very late (>1 year after stent implantation).1
2 mm
JCM-D-13-00624
Images in cardiovascular medicine
Optical coherence tomography-guided treatment of very late stent thrombosis caused by inaccurate stent deployment in a bifurcation Francesco De Caro, Marco De Carlo and Anna S. Petronio A 65-year-old man presented at our institution with anterior wall reinfarction, due to very late stent thrombosis, 4 years after primary angioplasty on the first bifurcation of the left anterior descending artery. Using intravascular optical coherence tomography, we identified stent malapposition in the proximal left anterior descending artery, occurring during the first primary angioplasty, as the probable cause of the very late stent thrombosis. Imaging with optical coherence tomography guided our treatment strategy of mechanical and pharmacological thrombectomy, followed by staged stent postdilatation.
J Cardiovasc Med 2014, 15:000–000
In 2009, a 60-year-old man underwent primary angioplasty for anterior myocardial infarction with deployment of two drug-eluting stents, a Cypher 2.5 8 mm (Cordis Corp., Johnson & Johnson, Warren, New Jersey, USA) in the mid left anterior descending artery (LAD), and a Xience V 2.5 28 mm (Abbott Vascular, Santa Clara, California, USA), proximal to the Cypher stent, extending into the bifurcation of the proximal LAD with a large first diagonal branch (Fig. 1). Four years later, the patient presented with anterior wall reinfarction; coronary angiography showed subocclusive thrombosis at the proximal edge of the Xience stent (Fig. 2, arrow), with distal LAD embolization. After successful rheolytic thrombectomy and intracoronary administration of a bolus of abciximab 0.25 mg/kg (Fig. 3), optical coherence tomography (OCT) revealed an abrupt change in the diameter of
the LAD at the transition between the proximal and mid portion (from 3.6 to 2.7 mm), resulting in partial malapposition of the proximal 2 mm of the Xience stent, with scarce residual thrombus on the nonendothelized stent struts (Fig. 4, arrows). The remaining length of the Xience stent was well apposed, adequately expanded, and completely endothelized, with no evidence of thrombus. Immediately after the procedure, the patient received 12-h abciximab 0.125 mg/kg/min intravenous infusion, and prasugrel 60 mg oral loading dose. After 4 days, OCT performed during elective coronary angiography showed complete resolution of thrombosis in the malapposed proximal edge of the Xience stent (Fig. 5), which we decided to postdilate aggressively with a 4 mm noncompliant balloon (Fig. 6) in order to achieve apposition to the vessel wall. We completed the procedure with
Keywords: endothelization, intravascular imaging, optical coherence tomography, stent thrombosis Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, University of Pisa, Pisa, Italy Correspondence to Francesco De Caro, MD, Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Ospedale Cisanello, Via Paradisa 2, 56124 Pisa, Italy Tel: +39 050 995330; fax: +39 050 995325; e-mail: [email protected] Received 19 November 2013 Revised 5 April 2014 Accepted 7 April 2014
Fig. 1
(a)
(b)
(a) Left coronary angiogram during the first primary angioplasty in 2009, showing the subocclusion of the mid left anterior descending artery, just distal to the bifurcation with a large first diagonal branch (arrow). (b) Final result after angioplasty.
1558-2027 ß 2014 Italian Federation of Cardiology
DOI:10.2459/JCM.0000000000000126
Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.
CE: Namrta; JCM-D-13-00624; Total nos of Pages: 4;
JCM-D-13-00624
2 Journal of Cardiovascular Medicine 2014, Vol 00 No 00
Fig. 2
Fig. 4
Zoom: 1.7x 10
20
30
40
mm
2 0
Left coronary angiogram during the second primary angioplasty in 2013, showing the presence of thrombus at the proximal edge of the stent implanted in the mid left anterior descending artery (LAD) (arrow).
deployment of a new Xience V 4.0 8 mm stent, overlapping the first 1.5 mm of the previously implanted Xience stent (Fig. 7). Stent thrombosis is a potentially life-threatening complication of percutaneous coronary intervention. According to the timing of the onset, stent thrombosis is classified as early (differentiated in acute between 0 and 24 h and subacute between 24 h and 30 days after stent implantation), late (>30 days to 1 year after stent implantation), or very late (>1 year after stent implantation).1
2 mm
