Author + information
- Received March 16, 2016
- Accepted March 24, 2016
- Published online July 11, 2016.
- Hiroyoshi Mori, MDa,
- Aloke V. Finn, MDa,
- James B. Atkinson, MDb,
- Christoph Lutter, MDa,
- Jagat Narula, MDc and
- Renu Virmani, MDa,∗ ()
- aCVPath Institute, Gaithersburg, Maryland
- bDepartment of Pathology, Vanderbilt University Medical Center, Nashville, Tennessee
- cIchan School of Medicine at Mount Sinai, New York, New York
- ↵∗Reprint requests and correspondence author:
Dr. Renu Virmani, CVPath Institute, 19 Firstfield Road, Gaithersburg, Maryland 20878.
Calcified nodule is a rare cause of coronary events, especially in in-stent thrombosis (1). Calcified sheets or plates break and form nodules of calcification and when they protrude into the lumen are associated with platelet-rich thrombi (1).
Case 1 (Figure 1A) was a 92-year-old woman who died of respiratory failure 9 days following transcatheter aortic valve replacement. A bare-metal stent (Wallstent, Boston Scientific, Natick, Massachusetts) had been implanted in the proximal right coronary artery when she was 77 years of age. Histological sections from the right coronary ostium revealed the underlying atherosclerotic plaque to be highly calcified, with nodules protruding into the lumen that likely led to early luminal thrombosis that organized, resulting in chronic total occlusion.
Case 2 (Figure 1B) was a 60-year-old man who died of fulminant hepatitis. Post-mortem radiographs revealed extensive calcification within the proximal right coronary artery, with the presence of 2 nonoverlapping Palmaz-Schatz bare-metal stents (Cordis Corporation, Miami Lakes, Florida). Histologic sections showed an underlying fibrocalcific plaque with a sheet of calcium and nodular calcification. Unlike the first case, there was a well-formed neointima consisting of smooth muscle cells within a proteoglycan-collagen-rich matrix. However, the lumen showed the presence of a large number of nodules of calcium, which were surrounded focally by fibrin. A few struts were enveloped by calcium, suggestive of in situ calcification. The formation of calcified nodules appears to have resulted in stent thrombosis with organization and chronic total occlusion.
Both lesions illustrate the presence of nodular calcification within the lumen that resulted in stent thrombosis and chronic total occlusion. In the first case, protrusion of calcified nodular plaque led to early luminal thrombosis, while in the second case represents de novo nodular calcification within the neointima that protruded into the lumen. The calcium formed over the years around the stent struts and eventually broke into pieces, resulting in luminal thrombus. To the best of our knowledge, de novo nodular calcification after stent placement has never been reported. Current intravascular imaging modalities should be able to visualize calcified nodules in stented lesions, as has been described previously (2).
CVPath Institute receives research grants from Medtronic CardioVascular, Abbott Vascular, Terumo Corporation, Atrium Medical, Boston Scientific, Cordis/Johnson & Johnson, OrbusNeich Medical, and Biosensors International. Dr. Virmani has speaking engagements with Merck; receives honoraria from Abbott Vascular, Boston Scientific, Lutonix, Medtronic, and Terumo Corporation; and is a consultant for 480 Biomedical, Abbott Vascular, Medtronic, and W.L. Gore. Dr. Finn has sponsored research agreements with Medtronic CardioVascular and Boston Scientific; and is an advisory board member for Medtronic CardioVascular. Dr. Narula receives grants from GE Healthcare and Philips Healthcare. Dr. Mori has received honoraria from Abbott Vascular, Goodman, and Terumo Corporation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 16, 2016.
- Accepted March 24, 2016.
- American College of Cardiology Foundation