Author + information
- Received October 24, 2017
- Revision received November 13, 2017
- Accepted November 21, 2017
- Published online March 5, 2018.
- Cleverson Zukowski, MDa,
- Felipe Maia, MDa,
- Maurício Oliveira, MDa,
- Luiz A. Mattos, MD, PhDa,
- Alvaro Pontes, MDa,
- Ricardo A. Costa, MD, PhDb,c and
- Daniel Chamié, MDb,c,∗ ()
- aHospital Copa D’Or, Rio de Janeiro, Brazil
- bDepartment of Interventional Cardiology, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
- cCardiovascular Research Center, São Paulo, Brazil
- ↵∗Address for correspondence:
Dr. Daniel Chamié, Dante Pazzanese Institute of Cardiology, Interventional Cardiology Department, 500 Dr. Dante Pazzanese Avenue, Ibirapuera, Sao Paulo, SP 04012-180, Brazil.
A 69-year-old man underwent percutaneous coronary intervention of a left anterior descending coronary artery (LAD) diagonal bifurcation lesion with 2 platinum-chromium everolimus-eluting stents with the culotte technique in September 2014. Dual-antiplatelet therapy was maintained for 1 year. In March 2016 (18 months later), while only on aspirin, the patient presented with anterolateral wall ST-segment elevation acute myocardial infarction and pulmonary edema while in treatment for community-acquired pneumonia. Emergent coronary angiography revealed in-stent haziness in the LAD immediately proximal to the bifurcation, extending into the diagonal branch. TIMI (Thrombolysis In Myocardial Infarction) flow was grade 3 in the LAD and grade 1 in the diagonal branch (Figure 1, Online Video 1).
Optical coherence tomography revealed complete coverage of the stent struts in the LAD stent distal to the carina of the bifurcation. The vascular response was mixed, with regions of peristrut low-intensity areas and lipid accumulation interspersed with normal-looking neointima. At the bifurcation site, a large thrombus burden was present, and the main vessel stents proximal to the side branch origin were crushed to 1 side of the vessel. Large malapposition was seen at the proximal stent edge (Figure 2, Online Video 2). Under reloading of aspirin 300 mg and loading of prasugrel 60 mg in addition to unfractionated heparin (70 U/kg) and abciximab (0.25 mg/kg bolus followed by 0.125 mg/kg/min maintenance for 12 h), the lesion was ultimately treated with a 4.0 × 15 mm zotarolimus-eluting stent (Figure 3).
Mechanical triggers are usually related to acute or subacute stent failures (1–3). This case illustrates an unusual situation of suboptimal stent implantation serving as a potential nidus for long-term percutaneous coronary intervention failure in association with a clinical condition. It underscores the importance of meticulous technique for bifurcation percutaneous coronary intervention, particularly when 2-stent techniques are used, and the role of intracoronary optical coherence tomography as an auxiliary method for understanding the mechanisms of failure and guiding subsequent management.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 24, 2017.
- Revision received November 13, 2017.
- Accepted November 21, 2017.
- 2018 American College of Cardiology Foundation
- Cheneau E.,
- Leborgne L.,
- Mintz G.S.,
- et al.
- van Werkum J.W.,
- Heestermans A.A.,
- Zomer A.C.,
- et al.