JACC: Cardiovascular Interventions
Extremely Late Catch-Up Phenomenon After First-Generation Sirolimus-Eluting Stent in the Left Main StemInsights From Optical Coherence Tomography
Author + information
- Toru Naganuma, MD∗∗ (torunaganuma{at}gmail.com),
- Yusuke Fujino, MD, PhD∗,
- Satoko Tahara, MD, PhD∗,
- Satoru Mitomo, MD∗,
- Sandeep Basavarajaiah, MD† and
- Sunao Nakamura, MD, PhD∗
- ∗Department of Cardiology, New Tokyo Hospital, Chiba, Japan
- †Department of Cardiology, Heart of England NHS Trust, Birmingham, United Kingdom
- ↵∗Reprint requests and correspondence:
Dr. Toru Naganuma, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 270-2232, Japan.
A 72-year-old man had undergone angioplasty of the left main stem (LMS) with an implantation of a first-generation drug-eluting stent (DES) (3.5 × 18-mm Cypher stent, Cordis, Johnson & Johnson, Bridgewater, New Jersey) (Figure 1A). Post-procedural intravascular ultrasound (IVUS) had shown a well-expanded stent (Figures 1A′ and 1Aa–c). Four years later, both angiography and IVUS exhibited no significant in-stent restenosis (ISR) or stent recoil (Figures 1B, 1B′, and 1Ba′–c′). At 7 years, he presented with acute coronary syndrome (ACS) while still on long-term dual antiplatelet therapy. A subsequently obtained coronary angiogram exhibited severe ISR at the midshaft of LMS (Figure 1C). Pre-procedural optical coherence tomography (OCT) showed a massive low-intensity neointimal plaque including microvessels, indicating neoatherosclerosis, within the stent (Figures 1C′′ and 1a′′–g′′). In addition, a plaque rupture was noted at distal shoulder of the plaque with white thrombi (Figures 2A and 2B). There was no evidence of malapposed struts. Successful revascularization was performed using a new-generation DES.
Serial Assessments of LMS With Angiography, IVUS, and OCT
(A) Post-procedural angiography showing an excellent result after a 3.5 × 18-mm Cypher stent (Cordis, Johnson & Johnson, Bridgewater, New Jersey) implantation followed by post-dilation with a 4.0-mm noncompliant balloon. (A′) Post-procedural IVUS longitudinal view. (a to c) IVUS showing a well-expanded stent (stent area, 10.3 mm2; stent diameter, 3.3 × 4.0-mm [a]). (B) Angiography at 4 years with no restenosis. (B′) IVUS longitudinal view at 4 years. (a′ to c′) IVUS showing adequate lumen and stent areas (stent diameter and area were quite similar to post-procedural ones). (C) Angiography at 7 years showing a focal severe in-stent restenosis at the LMS midshaft. (C′′) OCT longitudinal view at 7 years (a rupture site in the distal shoulder of the in-stent neointimal plaque is indicated with a red arrow). (a′′) OCT showing a low-intensity neointimal plaque with a few white thrombi at the site with minimal lumen area (stent area, 8.0 mm2; stent diameter, 3.2 × 3.4-mm; lumen area, 1.3 mm2). (b′′) OCT showing a low-intensity neointimal plaque with no evident uncovered and/or malapposed stent struts as well as stent fracture. (c′′) OCT showing proximal part of the left main with adequate lumen and stent areas. (d′′) OCT showing a LAD/LCx bifurcation site. (e′′) OCT showing white thrombi (indicated by white arrows). (f′′) OCT showing a neointimal plaque rupture in the distal shoulder with a thin flap. (g′′) OCT showing microvessels within the neointimal plaque (indicated by white arrows). IVUS = intravascular ultrasound; LAD = left anterior descending artery; LCx = left circumflex artery; LMS = left main stem; OCT = optical coherence tomography.
OCT 3-Dimensional Reconstruction Images
(A) OCT 3-dimensional reconstruction image confirming a neointimal plaque rupture as a cavity in its distal shoulder (a view from the LAD toward the LMS). (B) OCT 3-dimensional reconstruction image confirming a neointimal plaque rupture as a cavity in its distal shoulder (a vertical section). Abbreviations as in Figure 1.
Although “late catch-up” is a well-known complication after first-generation DES implantation (1,2), our case demonstrates that this unfavorable phenomenon can occur even at an extremely late phase after stenting. Approximately 30% of ISR presents as ACS (3), and, as seen in our case, it might be due to plaque rupture from neoatherosclerosis within the stent illustrated by some excellent OCT images. A previous IVUS study on ACS demonstrated that rupture at the distal shoulder of plaque is associated with less dramatic electrocardiographic changes and relatively higher grade of Thrombolysis In Myocardial Infarction flow grade (4). The plaque rupture at the distal shoulder in our case might explain the reason why our patient could survive with ACS of the LMS.
Footnotes
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 15, 2015.
- Accepted June 19, 2015.
- American College of Cardiology Foundation
