International Journal of Cardiology 197 (2015) 113–115
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Accidentally crushed stent during complex bifurcation treatment. A potential cause of very late stent thrombosis Morten Würtz a,b, Evald Høj Christiansen a, Steen Dalby Kristensen a, Niels Ramsing Holm a,⁎ a b
Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark Department of Internal Medicine, Regional Hospital West Jutland, Denmark
a r t i c l e
i n f o
Article history: Received 31 May 2015 Accepted 18 June 2015 Available online 19 June 2015 Keywords: Stent thrombosis Drug eluting stents Coronary bifurcation Optical coherence tomography
© 2015 Elsevier Ireland Ltd. All rights reserved.
Patients treated with first generation drug-eluting stents (DES) are at increased risk of very late stent thrombosis due to heterogeneous healing patterns including uncovered struts, stent malapposition, evaginations, aneurysm formation, and accelerated neoatherosclerosis caused by hyper-sensitivity reactions towards the permanent stent polymer [1,2]. Inadequate stent implantation techniques resulting in insufficient lesion coverage, acute malapposition [3], multiple strut layers [4] and stent underexpansion [5] may further contribute to increased risk of late events. Complex treatment of coronary bifurcation lesions using first generation DES is associated with inferior long-term outcome compared to provisional stenting [6]. The increased load of stent in twostent techniques may be a major contributing factor for late events but suboptimal implantation techniques may also affect long-term outcome as severely malapposed struts and overlapping segments are healing at a slower pace. In the era of high-resolution intra coronary imaging, retrospective findings reveal procedural issues with a late but high penalty. A male patient in the early sixties with non-ST-elevation myocardial infarction was treated for an LAD/D1 bifurcation lesion (Medina class 1,1,1) (Fig. 1A) and was readmitted 6 years later in bad conditions with stent thrombosis (ST) (Fig. 1C). At the index procedure, the patient was treated by the two-stent culotte technique after randomization in the ⁎ Corresponding author at: Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark. E-mail address: [email protected] (N.R. Holm).
http://dx.doi.org/10.1016/j.ijcard.2015.06.045 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Nordic Bifurcation Study II [7]. Two drug eluting stents (Cypher Select®, Cordis, USA) were deployed by initial stenting of the side branch and subsequent stenting of the main vessel (Fig. 1B). The prescheduled study angiography performed eight months later indicated no adverse healing process and intravascular ultra sound (IVUS) was considered normal at the time. Six years later the patient developed acute chest pain and cardiac arrest. After successful resuscitation, the ECG showed ST-segment elevations in leads V1–V5 and acute angiography revealed total occlusion of the LAD stent extending into the proximal part of the side branch stent (Fig. 1C). LAD and D1 were wired with some difficulty and dilated with 20 × 3.5 mm and 20 × 2.5 mm balloons respectively restoring TIMI 3 flow. Attempts to advance a thrombectomy catheter were unsuccessful and the procedure was terminated with the patient in stable conditions. Re-angiography 24 h later showed open stents but malapposed, and uncovered stent struts at the proximal main vessel stent edge were identified by OCT (Fig. 1, panel E). Three strut layers at one side of the proximal main vessel (Fig. 2) suggested an originally crushed stent due to accidental abluminal advancement of the second guide wire in the proximal main vessel part of the side branch stent before dilatation and implantation of the main vessel stent (Fig. 1D). This example of suboptimal complex bifurcation treatment with subsequent very late stent thrombosis illustrates the continuous risk after treatment by first generation drug-eluting stents [8] augmented by multiple overlapping strut layers [4]. The case further emphasizes that rewiring during bifurcation stenting entails a risk of accidental abluminal rewiring and subsequent crushing of the proximal stent segments. Crushed stents provide limited radial support and severe
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M. Würtz et al. / International Journal of Cardiology 197 (2015) 113–115
Fig. 1. Patient with non-ST-elevation myocardial infarction due to a bifurcation lesion in the left anterior descending artery (LAD) and 1st diagonal branch (A). (B), Final angiographic result after culotte two-stent treatment. (C), Stent thrombosis six years after the index procedure. (D) Reconstruction of the index procedure: (D1) implanting the side branch stent extending into the main vessel, (D2) rewiring the main vessel, but with accidental abluminal rewiring of the proximal main vessel (crossing point: yellow arrow), (D3) balloon inflation in the main vessel thereby crushing the proximal part of the main vessel stent, (D4) main vessel stent implantation and subsequent rewiring of the side branch, (D5) kissing balloon inflation. (E), Final result. OCT findings after balloon-treated stent thrombosis. (E1) Crushed segment with dual stent layers. Visible thrombus on struts, (E2) edge of main vessel stent with struts covering the crushed side branch stent, (E3) main vessel stent jailing the crushed side branch stent, (E4) circular dual stent layers, (E5) bifurcation core segment showing jailing struts with attached thrombus, (E6) distal main vessel with a healed single strut layer.
malapposition may persist even at long-term follow-up. Proximal postdilatation (POT: proximal optimization technique [9]) may be applied for reducing malapposition [10] and if performed before rewiring it may further reduce the risk of advancing the second wire behind the stent. Still OCT may be used to exclude accidental abluminal rewiring which is always a risk when advancing wires in implanted stents where strut apposition is unknown or evidently incomplete.
Potential conflicts of interest MW and SDK report no potential conflicts of interest. EHC has received institutional research grants by Cordis, St. Jude Medical and Terumo and speakers fee by St. Jude Medical. NRH has received institutional research grants by Cordis, St. Jude Medical and Terumo and speakers fee by St. Jude Medical and Terumo.
Fig. 2. Intravascular imaging of the proximal LAD stent edge six years after index PCI. (A), Optical coherence tomography shows multiple stent strut layers (red arrows) suggesting crushing of the stent. Intimal bridging (yellow arrow) induced by non-uniform healing patterns on malapposed struts. (B), Retrospectively, the proximal stent crush (red arrows) was visible by IVUS performed eight months after index PCI.
M. Würtz et al. / International Journal of Cardiology 197 (2015) 113–115
Acknowledgements Cordis, US, provided an institutional research grant for The Nordic Bifurcation study II. References [1] L. Raber, S. Baumgartner, H.M. Garcia, B. Kalesan, J. Justiz, T. Pilgrim, A. Moschovitis, A.A. Khattab, L. Buellesfeld, P. Wenaweser, B. Meier, P.W. Serruys, P. Juni, S. Windecker, Long-term vascular healing in response to sirolimus- and Paclitaxeleluting stents: an optical coherence tomography study, JACC Cardiovasc. Interv. 5 (2012) 946–957. [2] S. Cook, P. Wenaweser, M. Togni, M. Billinger, C. Morger, C. Seiler, R. Vogel, O. Hess, B. Meier, S. Windecker, Incomplete stent apposition and very late stent thrombosis after drug-eluting stent implantation, Circulation 115 (2007) 2426–2434. [3] S. Cook, P. Eshtehardi, B. Kalesan, L. Raber, P. Wenaweser, M. Togni, A. Moschovitis, R. Vogel, C. Seiler, F.R. Eberli, T. Luscher, B. Meier, P. Juni, S. Windecker, Impact of incomplete stent apposition on long-term clinical outcome after drug-eluting stent implantation, Eur. Heart J. 33 (2012) 1334–1343. [4] J.L. Gutierrez-Chico, L. Raber, E. Regar, T. Okamura, C. di Mario, G.A. van Es, S. Windecker, P.W. Serruys, Tissue coverage and neointimal hyperplasia in overlap versus nonoverlap segments of drug-eluting stents 9 to 13 months after implantation: in vivo assessment with optical coherence tomography, Am. Heart J. 166 (2013) 83–94. [5] I. Moussa, J. Moses, C. Di Mario, R. Albiero, J. De Gregorio, M. Adamian, L. Di Francesco, A. Colombo, Does the specific intravascular ultrasound criterion used to optimize stent expansion have an impact on the probability of stent restenosis? Am. J. Cardiol. 83 (1999) 1012–1017.
115
[6] M. Maeng, N.R. Holm, A. Erglis, I. Kumsars, M. Niemela, K. Kervinen, J.S. Jensen, A. Galloe, T.K. Steigen, R. Wiseth, I. Narbute, P. Gunnes, J. Mannsverk, O. Meyerdierks, S. Rotevatn, K. Nikus, S. Vikman, J. Ravkilde, S. James, J. Aaroe, A. Ylitalo, S. Helqvist, I. Sjogren, P. Thayssen, K. Virtanen, M. Puhakka, J. Airaksinen, E.H. Christiansen, J.F. Lassen, L. Thuesen, Long-term results after simple versus complex stenting of coronary artery bifurcation lesions: Nordic bifurcation study 5-year follow-up results, J. Am. Coll. Cardiol. 62 (2013) 30–34. [7] K. Kervinen, M. Niemela, H. Romppanen, A. Erglis, I. Kumsars, M. Maeng, N.R. Holm, J.F. Lassen, P. Gunnes, S. Stavnes, J.S. Jensen, A. Galloe, I. Narbute, D. Sondore, E.H. Christiansen, J. Ravkilde, T.K. Steigen, J. Mannsverk, P. Thayssen, K.N. Hansen, S. Helqvist, S. Vikman, R. Wiseth, J. Aaroe, J. Jokelainen, L. Thuesen, Nordic PCI Study Group, Clinical outcome after crush versus culotte stenting of coronary artery bifurcation lesions: the Nordic stent technique study 36-month follow-up results, JACC Cardiovasc. Interv. 6 (2013) 1160–1165. [8] G. Nakazawa, A.V. Finn, M. Vorpahl, E.R. Ladich, F.D. Kolodgie, R. Virmani, Coronary responses and differential mechanisms of late stent thrombosis attributed to firstgeneration sirolimus- and paclitaxel-eluting stents, J. Am. Coll. Cardiol. 57 (2011) 390–398. [9] J.F. Lassen, N.R. Holm, G. Stankovic, T. Lefevre, A. Chieffo, D. Hildick-Smith, M. Pan, O. Darremont, R. Albiero, M. Ferenc, Y. Louvard, Percutaneous coronary intervention for coronary bifurcation disease: consensus from the first 10 years of the European Bifurcation Club meetings, EuroIntervention 10 (2014) 545–560. [10] N. Foin, G.G. Secco, L. Ghilencea, R. Krams, M.C. Di, Final proximal post-dilatation is necessary after kissing balloon in bifurcation stenting, EuroIntervention 7 (2011) 597–604.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Accidentally crushed stent during complex bifurcation treatment. A potential cause of very late stent thrombosis Morten Würtz a,b, Evald Høj Christiansen a, Steen Dalby Kristensen a, Niels Ramsing Holm a,⁎ a b
Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark Department of Internal Medicine, Regional Hospital West Jutland, Denmark
a r t i c l e
i n f o
Article history: Received 31 May 2015 Accepted 18 June 2015 Available online 19 June 2015 Keywords: Stent thrombosis Drug eluting stents Coronary bifurcation Optical coherence tomography
© 2015 Elsevier Ireland Ltd. All rights reserved.
Patients treated with first generation drug-eluting stents (DES) are at increased risk of very late stent thrombosis due to heterogeneous healing patterns including uncovered struts, stent malapposition, evaginations, aneurysm formation, and accelerated neoatherosclerosis caused by hyper-sensitivity reactions towards the permanent stent polymer [1,2]. Inadequate stent implantation techniques resulting in insufficient lesion coverage, acute malapposition [3], multiple strut layers [4] and stent underexpansion [5] may further contribute to increased risk of late events. Complex treatment of coronary bifurcation lesions using first generation DES is associated with inferior long-term outcome compared to provisional stenting [6]. The increased load of stent in twostent techniques may be a major contributing factor for late events but suboptimal implantation techniques may also affect long-term outcome as severely malapposed struts and overlapping segments are healing at a slower pace. In the era of high-resolution intra coronary imaging, retrospective findings reveal procedural issues with a late but high penalty. A male patient in the early sixties with non-ST-elevation myocardial infarction was treated for an LAD/D1 bifurcation lesion (Medina class 1,1,1) (Fig. 1A) and was readmitted 6 years later in bad conditions with stent thrombosis (ST) (Fig. 1C). At the index procedure, the patient was treated by the two-stent culotte technique after randomization in the ⁎ Corresponding author at: Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark. E-mail address: [email protected] (N.R. Holm).
http://dx.doi.org/10.1016/j.ijcard.2015.06.045 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Nordic Bifurcation Study II [7]. Two drug eluting stents (Cypher Select®, Cordis, USA) were deployed by initial stenting of the side branch and subsequent stenting of the main vessel (Fig. 1B). The prescheduled study angiography performed eight months later indicated no adverse healing process and intravascular ultra sound (IVUS) was considered normal at the time. Six years later the patient developed acute chest pain and cardiac arrest. After successful resuscitation, the ECG showed ST-segment elevations in leads V1–V5 and acute angiography revealed total occlusion of the LAD stent extending into the proximal part of the side branch stent (Fig. 1C). LAD and D1 were wired with some difficulty and dilated with 20 × 3.5 mm and 20 × 2.5 mm balloons respectively restoring TIMI 3 flow. Attempts to advance a thrombectomy catheter were unsuccessful and the procedure was terminated with the patient in stable conditions. Re-angiography 24 h later showed open stents but malapposed, and uncovered stent struts at the proximal main vessel stent edge were identified by OCT (Fig. 1, panel E). Three strut layers at one side of the proximal main vessel (Fig. 2) suggested an originally crushed stent due to accidental abluminal advancement of the second guide wire in the proximal main vessel part of the side branch stent before dilatation and implantation of the main vessel stent (Fig. 1D). This example of suboptimal complex bifurcation treatment with subsequent very late stent thrombosis illustrates the continuous risk after treatment by first generation drug-eluting stents [8] augmented by multiple overlapping strut layers [4]. The case further emphasizes that rewiring during bifurcation stenting entails a risk of accidental abluminal rewiring and subsequent crushing of the proximal stent segments. Crushed stents provide limited radial support and severe
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M. Würtz et al. / International Journal of Cardiology 197 (2015) 113–115
Fig. 1. Patient with non-ST-elevation myocardial infarction due to a bifurcation lesion in the left anterior descending artery (LAD) and 1st diagonal branch (A). (B), Final angiographic result after culotte two-stent treatment. (C), Stent thrombosis six years after the index procedure. (D) Reconstruction of the index procedure: (D1) implanting the side branch stent extending into the main vessel, (D2) rewiring the main vessel, but with accidental abluminal rewiring of the proximal main vessel (crossing point: yellow arrow), (D3) balloon inflation in the main vessel thereby crushing the proximal part of the main vessel stent, (D4) main vessel stent implantation and subsequent rewiring of the side branch, (D5) kissing balloon inflation. (E), Final result. OCT findings after balloon-treated stent thrombosis. (E1) Crushed segment with dual stent layers. Visible thrombus on struts, (E2) edge of main vessel stent with struts covering the crushed side branch stent, (E3) main vessel stent jailing the crushed side branch stent, (E4) circular dual stent layers, (E5) bifurcation core segment showing jailing struts with attached thrombus, (E6) distal main vessel with a healed single strut layer.
malapposition may persist even at long-term follow-up. Proximal postdilatation (POT: proximal optimization technique [9]) may be applied for reducing malapposition [10] and if performed before rewiring it may further reduce the risk of advancing the second wire behind the stent. Still OCT may be used to exclude accidental abluminal rewiring which is always a risk when advancing wires in implanted stents where strut apposition is unknown or evidently incomplete.
Potential conflicts of interest MW and SDK report no potential conflicts of interest. EHC has received institutional research grants by Cordis, St. Jude Medical and Terumo and speakers fee by St. Jude Medical. NRH has received institutional research grants by Cordis, St. Jude Medical and Terumo and speakers fee by St. Jude Medical and Terumo.
Fig. 2. Intravascular imaging of the proximal LAD stent edge six years after index PCI. (A), Optical coherence tomography shows multiple stent strut layers (red arrows) suggesting crushing of the stent. Intimal bridging (yellow arrow) induced by non-uniform healing patterns on malapposed struts. (B), Retrospectively, the proximal stent crush (red arrows) was visible by IVUS performed eight months after index PCI.
M. Würtz et al. / International Journal of Cardiology 197 (2015) 113–115
Acknowledgements Cordis, US, provided an institutional research grant for The Nordic Bifurcation study II. References [1] L. Raber, S. Baumgartner, H.M. Garcia, B. Kalesan, J. Justiz, T. Pilgrim, A. Moschovitis, A.A. Khattab, L. Buellesfeld, P. Wenaweser, B. Meier, P.W. Serruys, P. Juni, S. Windecker, Long-term vascular healing in response to sirolimus- and Paclitaxeleluting stents: an optical coherence tomography study, JACC Cardiovasc. Interv. 5 (2012) 946–957. [2] S. Cook, P. Wenaweser, M. Togni, M. Billinger, C. Morger, C. Seiler, R. Vogel, O. Hess, B. Meier, S. Windecker, Incomplete stent apposition and very late stent thrombosis after drug-eluting stent implantation, Circulation 115 (2007) 2426–2434. [3] S. Cook, P. Eshtehardi, B. Kalesan, L. Raber, P. Wenaweser, M. Togni, A. Moschovitis, R. Vogel, C. Seiler, F.R. Eberli, T. Luscher, B. Meier, P. Juni, S. Windecker, Impact of incomplete stent apposition on long-term clinical outcome after drug-eluting stent implantation, Eur. Heart J. 33 (2012) 1334–1343. [4] J.L. Gutierrez-Chico, L. Raber, E. Regar, T. Okamura, C. di Mario, G.A. van Es, S. Windecker, P.W. Serruys, Tissue coverage and neointimal hyperplasia in overlap versus nonoverlap segments of drug-eluting stents 9 to 13 months after implantation: in vivo assessment with optical coherence tomography, Am. Heart J. 166 (2013) 83–94. [5] I. Moussa, J. Moses, C. Di Mario, R. Albiero, J. De Gregorio, M. Adamian, L. Di Francesco, A. Colombo, Does the specific intravascular ultrasound criterion used to optimize stent expansion have an impact on the probability of stent restenosis? Am. J. Cardiol. 83 (1999) 1012–1017.
115
[6] M. Maeng, N.R. Holm, A. Erglis, I. Kumsars, M. Niemela, K. Kervinen, J.S. Jensen, A. Galloe, T.K. Steigen, R. Wiseth, I. Narbute, P. Gunnes, J. Mannsverk, O. Meyerdierks, S. Rotevatn, K. Nikus, S. Vikman, J. Ravkilde, S. James, J. Aaroe, A. Ylitalo, S. Helqvist, I. Sjogren, P. Thayssen, K. Virtanen, M. Puhakka, J. Airaksinen, E.H. Christiansen, J.F. Lassen, L. Thuesen, Long-term results after simple versus complex stenting of coronary artery bifurcation lesions: Nordic bifurcation study 5-year follow-up results, J. Am. Coll. Cardiol. 62 (2013) 30–34. [7] K. Kervinen, M. Niemela, H. Romppanen, A. Erglis, I. Kumsars, M. Maeng, N.R. Holm, J.F. Lassen, P. Gunnes, S. Stavnes, J.S. Jensen, A. Galloe, I. Narbute, D. Sondore, E.H. Christiansen, J. Ravkilde, T.K. Steigen, J. Mannsverk, P. Thayssen, K.N. Hansen, S. Helqvist, S. Vikman, R. Wiseth, J. Aaroe, J. Jokelainen, L. Thuesen, Nordic PCI Study Group, Clinical outcome after crush versus culotte stenting of coronary artery bifurcation lesions: the Nordic stent technique study 36-month follow-up results, JACC Cardiovasc. Interv. 6 (2013) 1160–1165. [8] G. Nakazawa, A.V. Finn, M. Vorpahl, E.R. Ladich, F.D. Kolodgie, R. Virmani, Coronary responses and differential mechanisms of late stent thrombosis attributed to firstgeneration sirolimus- and paclitaxel-eluting stents, J. Am. Coll. Cardiol. 57 (2011) 390–398. [9] J.F. Lassen, N.R. Holm, G. Stankovic, T. Lefevre, A. Chieffo, D. Hildick-Smith, M. Pan, O. Darremont, R. Albiero, M. Ferenc, Y. Louvard, Percutaneous coronary intervention for coronary bifurcation disease: consensus from the first 10 years of the European Bifurcation Club meetings, EuroIntervention 10 (2014) 545–560. [10] N. Foin, G.G. Secco, L. Ghilencea, R. Krams, M.C. Di, Final proximal post-dilatation is necessary after kissing balloon in bifurcation stenting, EuroIntervention 7 (2011) 597–604.
