Author + information
- Received July 20, 2015
- Accepted July 31, 2015
- Published online December 28, 2015.
- ∗Thoraxcentre, Erasmus Medical Centre, Rotterdam, the Netherlands
- †National Heart Centre Singapore, Singapore
- ↵∗Reprint requests and correspondence:
Dr. Jiang Ming Fam, Department of Cardiology, Thoraxcentre, Room Ba-585, Erasmus University Medical Center, ‘s-Gravendijkwal 230, 3015 GE Rotterdam, the Netherlands.
A 71-year-old man was admitted for acute coronary syndrome. Six weeks earlier, he had a Promus Premier 3.0 × 12-mm (Boston Scientific, Natick, Massachusetts) drug-eluting stent (DES) implanted in the obtuse marginal (OM) artery for unstable angina. On repeat coronary angiography, haziness (Figure 1A, Online Video 1) in the ostial stented region was observed; however Thrombolysis In Myocardial Infarction flow grade was good. Optical coherence tomography (OCT) revealed a nonexpanded stent (star with struts marked with +) within and protruding out of the deployed stent. The deployed stent appeared well expanded and apposed to the vessel wall (deployed stent with struts marked with asterisk [Figures 1C and 1D, Online Video 2]). There was lumen compromise secondary to a large amount of thrombus formation seen around the nonexpanded stent struts together with incomplete lesion coverage proximally. Attempts to rewire or retrieve the nonexpanded stent were unsuccessful. On the basis of the OCT findings, the decision was made to crush the nonexpanded stent and to deploy a Promus Premier 3.5 × 12-mm DES proximally with good results (angiography shown in Figure 1B, Online Video 3). Multiple layers of struts (OCT) (white arrows in Figure 1, D-3; Online Video 4) from the 2 overlapping deployed stents as well as the previously nonexpanded stent can be seen in Figures 1D and 1E. Figure 1F shows the 3-dimensional reconstruction (QAngioOCT software, Medis Specials, Leiden, the Netherlands) of the vessel pre- and post-procedure showing the crushed stent in stent.
We describe a rare cause of stent thrombosis, emphasizing that mechanical stent–related causes should always be ruled out, especially if stent thrombosis occurs soon after implantation. In our case, a nonexpanded stent formed the nidus of thrombus formation. The nonexpanded stent was likely due to loss or embolization during attempts at device delivery in a challenging procedure due to significant calcification, severe tortuosity, and suboptimal guide catheter backup. Of note, this complication was previously undetected on angiography. This is a rare case of stent-in-stent thrombosis in which OCT demonstrates the potential to improve clinical diagnosis and procedural outcome.
The authors thank Dr. Shengxian Tu for providing the QAngioOCT software used for the 3-dimensional rendering.
For supplemental videos, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 20, 2015.
- Accepted July 31, 2015.
- 2015 American College of Cardiology Foundation