International Journal of Cardiology 177 (2014) e4–e5
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Coronary artery aneurysm formation within everolimus-eluting bioresorbable stent Răzvan Şerban a, Alina Scridon a,b,⁎, Dan Dobreanu a,b, Ayman Elkaholut c a b c
Adults Cardiology Department (I), Emergency Institute for Cardiovascular Diseases and Transplantation Tîrgu Mureş, 540136 Tîrgu Mureş, Romania Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, 540139 Tîrgu Mureş, Romania Cardiac Catheterization Laboratory, Emergency Institute for Cardiovascular Diseases and Transplantation Tîrgu Mureş, 540136 Tîrgu Mureş, Romania
a r t i c l e
i n f o
Article history: Received 24 June 2014 Accepted 27 July 2014 Available online 5 August 2014 Keywords: Coronary aneurysm Bioresorbable coronary scaffold Coronary angioplasty
Recent technological advances have provided fully absorbable scaffolds available for coronary angioplasty. These new materials ensure both mechanical support for the coronary artery and drug-elution, while presenting the advantage of full absorption into the vessel wall after a predetermined interval of time. This later feature appears to ensure full restoration of the vasomotor function and of physiological responses of the stented and peri-stented segments to vasoactive stimuli, while avoiding long-term stent-related complications [1]. However, additional experience is needed in order to establish the entire spectrum of complications related to the use of these emerging materials. Herein we report the first case of coronary artery aneurysm formation within a new-generation, everolimus-eluting bioresorbable stent, with possible intra-scaffold thrombosis. A 45-year-old man with significant family history of coronary artery disease, active smoker, presented with chronic stable angina. Coronary angiogram (Fig. 1A) revealed a long, severe lesion, with possible proximal total occlusion, within the second segment of the right coronary artery (RCA). After difficult passage of the lesion with a hydrophilic guide-wire (Pilot 50; Abbott Vascular, Santa Clara, CA) using a 1.5 × 20 mm balloon to provide additional support and good predilation of the lesion with semi-compliant balloons up to a 1:1 balloon:stent ratio, the patient underwent stenting with a 3.0 × 28 mm everolimuseluting bioresorbable stent (Absorb; Abbott Vascular), followed by ⁎ Corresponding author at: Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, 38, Gheorghe Marinescu Street, 540139 Tîrgu Mureş, Romania. Tel.: +40 2 65 21 55 51 (175); fax: +40 2 65 21 04 07. E-mail address: [email protected] (A. Scridon).
http://dx.doi.org/10.1016/j.ijcard.2014.07.197 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
postdilation with a 3.5 × 15 mm noncompliant balloon, with good result and no angiographic evidence of residual stenosis or dissection in the stented segment (Fig. 1B). The patient was discharged on aspirin, clopidogrel, beta-blocker, angiotensin converting enzyme inhibitor, and statin. Six months later, the patient was readmitted to hospital for atypical chest pain. Coronary angiography revealed RCA aneurysm within the proximal region of the stented segment (Fig. 1C), confirmed on optical coherence tomography (OCT), which also showed partially resorbed scaffold (Fig. 1D) and suggested the presence of intra-scaffold thrombus (Fig. 1D; arrow). The aneurysm was judged not to be responsible for the patient's symptoms. The patient was discharged from hospital with no change in his drug regimen and scheduled for angiographic follow-up of the aneurysm 3 months later. During this interval the patient remained asymptomatic. Control coronary angiogram depicted mild progression of the aneurysm (Fig. 1E). Aneurysm formation within coronary stents is rare, with a reported incidence ranging between 0.3% and 6.0% [2]. Pathophysiological mechanisms such as exaggerated positive remodeling of the vessel wall with drug-eluting stents (DES), acute injury of the vessel wall at the site of stent deployment, persistent local hypersensitivity reaction to the stent polymer, the properties of the drug eluted by the stent, as well as stent malapposition, have been incriminated in the formation of stent-related aneurysms [3–5]. To date, coronary aneurysms have never been reported in relation to bioresorbable scaffolds. The exact mechanisms responsible for coronary aneurysm formation in this patient remain unknown. The angiographic appearance of RCA occlusion, with difficult passage of the guide-wire, may have led to sub-endothelial trajectory of the guide-wire with distal re-penetration into the vessel lumen and intima rupture, causing local microhemorrhage and/or ulceration, with consequent aneurysm formation. Local hypersensitivity reaction to the stent polymer occurring before complete resorption of the scaffold may also be involved. Additionally, since intravascular imaging was not used during the initial procedure, stent malapposition can neither be ruled out. According to previous studies, coronary aneurysms within DES appear to associate an increased risk of intra-stent thrombosis [5]. The intra-scaffold OCT image suggestive of thrombus in our patient indicates that this might also be the case for bioresorbable drug-eluting scaffolds. Bioresorbable coronary scaffolds are emerging materials in coronary angioplasty. Additional experience is needed before establishing the
R. Şerban et al. / International Journal of Cardiology 177 (2014) e4–e5
e5
Fig. 1. (A) Coronary angiogram of the right coronary artery (RCA) in left-anterior-oblique view showing a long, severe lesion, with possible proximal total occlusion within the second segment of the RCA (arrow), (B) treated with implantation of a 3.0 × 28 mm everolimus-eluting bioresorbable stent, with good angiographic result. (C) Repeat angiogram (6 months after stent implantation) of the RCA in left-anterior-oblique view showing RCA aneurysm within the proximal region of the stented segment (arrows). (D) Optical coherence tomography images showing partially resorbed scaffold and confirming the presence of coronary artery aneurysm within the stented segment. The arrow indicates an image suggestive of intra-scaffold thrombus. (E) Control coronary angiogram of the RCA in left-anterior-oblique view showing mild progression of the aneurysm (arrows).
entire spectrum of possible complications associated with their use. Meanwhile, intravascular imaging may be needed in order to accurately assess the results of stent deployment and apposition. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. Acknowledgments This work was partially supported by the University of Medicine and Pharmacy of Tîrgu Mureş Research Grant number 16/11.12.2013.
References [1] Serruys PW, Onuma Y, Dudek D, et al. Evaluation of the second generation of a bioresorbable everolimus-eluting vascular scaffold for the treatment of de novo coronary artery stenosis: 12-month clinical and imaging outcomes. J Am Coll Cardiol 2011; 58:1578–88. [2] Slota PA, Fischman DL, Savage M, Rake R, Goldberg S. Frequency and outcome of development of coronary artery aneurysm after intracoronary stent placement and angioplasty. Am J Cardiol 1997;79:1104–5. [3] Zhang F, Qian J, Dong L, Ge J. Coronary aneurysm formation following biodegradable polymer drug-eluting stent implantation. Int J Cardiol 2012;160(1):e8–9. [4] Kadakia MB, Epps KC, Julien ME, et al. Early aneurysm formation after everolimuseluting stent implantation. Circ Cardiovasc Interv 2014;7(2):266–7. [5] Alfonso F, Pérez-Vizcayno MJ, Ruiz M, et al. Coronary aneurysms after drug-eluting stent implantation: clinical, angiographic, and intravascular ultrasound findings. J Am Coll Cardiol 2009;53:2053–60.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Coronary artery aneurysm formation within everolimus-eluting bioresorbable stent Răzvan Şerban a, Alina Scridon a,b,⁎, Dan Dobreanu a,b, Ayman Elkaholut c a b c
Adults Cardiology Department (I), Emergency Institute for Cardiovascular Diseases and Transplantation Tîrgu Mureş, 540136 Tîrgu Mureş, Romania Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, 540139 Tîrgu Mureş, Romania Cardiac Catheterization Laboratory, Emergency Institute for Cardiovascular Diseases and Transplantation Tîrgu Mureş, 540136 Tîrgu Mureş, Romania
a r t i c l e
i n f o
Article history: Received 24 June 2014 Accepted 27 July 2014 Available online 5 August 2014 Keywords: Coronary aneurysm Bioresorbable coronary scaffold Coronary angioplasty
Recent technological advances have provided fully absorbable scaffolds available for coronary angioplasty. These new materials ensure both mechanical support for the coronary artery and drug-elution, while presenting the advantage of full absorption into the vessel wall after a predetermined interval of time. This later feature appears to ensure full restoration of the vasomotor function and of physiological responses of the stented and peri-stented segments to vasoactive stimuli, while avoiding long-term stent-related complications [1]. However, additional experience is needed in order to establish the entire spectrum of complications related to the use of these emerging materials. Herein we report the first case of coronary artery aneurysm formation within a new-generation, everolimus-eluting bioresorbable stent, with possible intra-scaffold thrombosis. A 45-year-old man with significant family history of coronary artery disease, active smoker, presented with chronic stable angina. Coronary angiogram (Fig. 1A) revealed a long, severe lesion, with possible proximal total occlusion, within the second segment of the right coronary artery (RCA). After difficult passage of the lesion with a hydrophilic guide-wire (Pilot 50; Abbott Vascular, Santa Clara, CA) using a 1.5 × 20 mm balloon to provide additional support and good predilation of the lesion with semi-compliant balloons up to a 1:1 balloon:stent ratio, the patient underwent stenting with a 3.0 × 28 mm everolimuseluting bioresorbable stent (Absorb; Abbott Vascular), followed by ⁎ Corresponding author at: Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, 38, Gheorghe Marinescu Street, 540139 Tîrgu Mureş, Romania. Tel.: +40 2 65 21 55 51 (175); fax: +40 2 65 21 04 07. E-mail address: [email protected] (A. Scridon).
http://dx.doi.org/10.1016/j.ijcard.2014.07.197 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
postdilation with a 3.5 × 15 mm noncompliant balloon, with good result and no angiographic evidence of residual stenosis or dissection in the stented segment (Fig. 1B). The patient was discharged on aspirin, clopidogrel, beta-blocker, angiotensin converting enzyme inhibitor, and statin. Six months later, the patient was readmitted to hospital for atypical chest pain. Coronary angiography revealed RCA aneurysm within the proximal region of the stented segment (Fig. 1C), confirmed on optical coherence tomography (OCT), which also showed partially resorbed scaffold (Fig. 1D) and suggested the presence of intra-scaffold thrombus (Fig. 1D; arrow). The aneurysm was judged not to be responsible for the patient's symptoms. The patient was discharged from hospital with no change in his drug regimen and scheduled for angiographic follow-up of the aneurysm 3 months later. During this interval the patient remained asymptomatic. Control coronary angiogram depicted mild progression of the aneurysm (Fig. 1E). Aneurysm formation within coronary stents is rare, with a reported incidence ranging between 0.3% and 6.0% [2]. Pathophysiological mechanisms such as exaggerated positive remodeling of the vessel wall with drug-eluting stents (DES), acute injury of the vessel wall at the site of stent deployment, persistent local hypersensitivity reaction to the stent polymer, the properties of the drug eluted by the stent, as well as stent malapposition, have been incriminated in the formation of stent-related aneurysms [3–5]. To date, coronary aneurysms have never been reported in relation to bioresorbable scaffolds. The exact mechanisms responsible for coronary aneurysm formation in this patient remain unknown. The angiographic appearance of RCA occlusion, with difficult passage of the guide-wire, may have led to sub-endothelial trajectory of the guide-wire with distal re-penetration into the vessel lumen and intima rupture, causing local microhemorrhage and/or ulceration, with consequent aneurysm formation. Local hypersensitivity reaction to the stent polymer occurring before complete resorption of the scaffold may also be involved. Additionally, since intravascular imaging was not used during the initial procedure, stent malapposition can neither be ruled out. According to previous studies, coronary aneurysms within DES appear to associate an increased risk of intra-stent thrombosis [5]. The intra-scaffold OCT image suggestive of thrombus in our patient indicates that this might also be the case for bioresorbable drug-eluting scaffolds. Bioresorbable coronary scaffolds are emerging materials in coronary angioplasty. Additional experience is needed before establishing the
R. Şerban et al. / International Journal of Cardiology 177 (2014) e4–e5
e5
Fig. 1. (A) Coronary angiogram of the right coronary artery (RCA) in left-anterior-oblique view showing a long, severe lesion, with possible proximal total occlusion within the second segment of the RCA (arrow), (B) treated with implantation of a 3.0 × 28 mm everolimus-eluting bioresorbable stent, with good angiographic result. (C) Repeat angiogram (6 months after stent implantation) of the RCA in left-anterior-oblique view showing RCA aneurysm within the proximal region of the stented segment (arrows). (D) Optical coherence tomography images showing partially resorbed scaffold and confirming the presence of coronary artery aneurysm within the stented segment. The arrow indicates an image suggestive of intra-scaffold thrombus. (E) Control coronary angiogram of the RCA in left-anterior-oblique view showing mild progression of the aneurysm (arrows).
entire spectrum of possible complications associated with their use. Meanwhile, intravascular imaging may be needed in order to accurately assess the results of stent deployment and apposition. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. Acknowledgments This work was partially supported by the University of Medicine and Pharmacy of Tîrgu Mureş Research Grant number 16/11.12.2013.
References [1] Serruys PW, Onuma Y, Dudek D, et al. Evaluation of the second generation of a bioresorbable everolimus-eluting vascular scaffold for the treatment of de novo coronary artery stenosis: 12-month clinical and imaging outcomes. J Am Coll Cardiol 2011; 58:1578–88. [2] Slota PA, Fischman DL, Savage M, Rake R, Goldberg S. Frequency and outcome of development of coronary artery aneurysm after intracoronary stent placement and angioplasty. Am J Cardiol 1997;79:1104–5. [3] Zhang F, Qian J, Dong L, Ge J. Coronary aneurysm formation following biodegradable polymer drug-eluting stent implantation. Int J Cardiol 2012;160(1):e8–9. [4] Kadakia MB, Epps KC, Julien ME, et al. Early aneurysm formation after everolimuseluting stent implantation. Circ Cardiovasc Interv 2014;7(2):266–7. [5] Alfonso F, Pérez-Vizcayno MJ, Ruiz M, et al. Coronary aneurysms after drug-eluting stent implantation: clinical, angiographic, and intravascular ultrasound findings. J Am Coll Cardiol 2009;53:2053–60.
