Author + information
- Received December 19, 2014
- Accepted December 31, 2014
- Published online May 1, 2015.
- Giuseppe Gargiulo, MD∗,
- Giovanni Longo, MD∗,
- Davide Capodanno, MD, PhD∗∗ (, )
- Bruno Francaviglia, MD∗,
- Piera Capranzano, MD∗ and
- Corrado Tamburino, MD, PhD∗,†
- ∗Division of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy
- †Excellence Through Newest Advances (ETNA) Foundation, Catania, Italy
- ↵∗Reprint requests and correspondence:
Dr. Davide Capodanno, University of Catania, Cardiovascular Department-Ferrarotto, Citelli 1, 95124 Catania, Italy.
A 48-year-old woman with history of multiple percutaneous coronary interventions and bypass grafting on the left anterior descending coronary artery presented with unstable angina. Coronary angiography showed a patent left internal mammary artery and de novo critical stenoses of the mid-shaft left main and the unprotected left circumflex coronary artery (LCX). Both lesions were treated with 2 nonoverlapping bioresorbable vascular scaffolds (BVS) (Absorb, Abbott Vascular, Santa Clara, California) 3.5 × 12 mm at 16 atm and 3.0 × 18 mm at 12 atm, respectively. Optical coherence tomography (OCT) confirmed good expansion and apposition of the BVS (Figure 1). A short rim of fracture was detected in the proximal portion of the left main BVS, which landed in healthy coronary segments both proximally and distally. No further action was undertaken.
Thirteen months later, the patient presented with unstable angina. The coronary angiography showed a critical focal restenosis of the BVS on the left main. The OCT demonstrated a severe multilayered pattern of neointimal proliferation with multiple areas of light attenuation suggestive for neoatherosclerosis (the largest one presenting with a partially disrupted cap). The previously detected rim of fracture was embedded in the neointimal tissue. After lesion pre-dilation, a zotarolimus-eluting stent 3.5 × 9 mm was implanted in-scaffold with a good final OCT result (Figure 1).
Mechanisms of restenosis of metallic stents include underexpansion, geographical missing, fracture, and drug resistance (1). Assuming similar etiologies for BVS, underexpansion and geographical missing were reasonably excluded by OCT at post-implantation (Figure 1). A causal role of the observed scaffold fracture (located 2.1 mm proximal to the site of restenosis) or drug resistance cannot be excluded. Also, the presence of neoatherosclerosis with disrupted cap could have played a causing role.
Management of BVS failure is not standardized. Balloon angioplasty or drug-eluting balloon were excluded, given the uncertain consequences inside a BVS with partially lost integrity as a result of the ongoing bioresorption process (2). Therefore, implantation of a metallic drug-eluting stent was preferred. A zotarolimus-eluting stent was chosen because of the previously observed failures of paclitaxel-, sirolimus-, and everolimus-eluting platforms.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 19, 2014.
- Accepted December 31, 2014.
- 2015 American College of Cardiology Foundation
- Alfonso F.,
- Byrne R.A.,
- Rivero F.,
- Kastrati A.
- Ohno Y.,
- Mangiameli A.,
- Attizzani G.F.,
- Capodanno D.,
- Tamburino C.