Int J Cardiovasc Imaging (2014) 30:1457–1459 DOI 10.1007/s10554-014-0506-9
IMAGES IN CV APPLICATIONS
OCT follow up of segmentally crushed stents in reopened coronary artery Bala´zs Tar • Istva´n Koo´s • Zsolt K} oszegi
Received: 24 June 2014 / Accepted: 21 July 2014 / Published online: 27 September 2014 Ó Springer Science+Business Media Dordrecht 2014
62 year old male patient had PCI by two DES implantation in October, 2012 (2.25/18 and 2.25/12 mm Resolute Integrity) because of subtotal occlusion on the medial part of the LAD distally to a very well developed diagonal branch. After one month he had a readmission with the symptoms of stent thrombosis (Fig. 1, left panel). During recanalization of the occluded stent by balloon angioplasty
Electronic supplementary material The online version of this article (doi:10.1007/s10554-014-0506-9) contains supplementary material, which is available to authorized users. B. Tar Z. K}oszegi Szabolcs – Szatma´r – Bereg County Hospitals and University Teaching Hospital, Nyı´regyha´za, Hungary I. Koo´s Borsod-Abau´j-Zemple´n County Hospital and University Teaching Hospital, Miskolc, Hungary Z. K}oszegi (&) Institute of Cardiology, University of Debrecen, Mo´ricz Zs. Krt. 22, 4004 Debrecen, Hungary e-mail: [email protected]
TIMI 3 flow was achieved, but slight haziness at the site of the stents raised the suspicion that the dilatation was performed partially outside the stent (Fig. 1, right upper panel). 2 months after the reintervention a follow up catheterization was performed in an OCT capable center. Coronary angiography showed patent LAD, while the OCT revealed that the stents had been crushed in 15 mm length to the one side of the vessel but the proximal and the distal part of the stented vessel segment showed good circumferential stent apposition. The crushed stent was filled by organized thrombi (Fig. 2, upper two left slices). After 1 year dual antiplatelet therapy another invasive investigation was decided. Functional assessment proved that the crushed stent caused only non-significant limitation in the hyperemic flow: FFR was determined to be 0.88. On the same time the repeated OCT investigation showed that the endoluminal surface of the crushed stent was completely endothelized (Figure 2, lower two left slices). These findings favored the discontinuation of the dual antiplatelet therapy. The further clinical follow up until now is uneventful. Our case shows the benefit of the OCT for clarifying the mechanism of the complication of the reintervention not detectable exactly by the angiogram: during the reopening of the occluded stents the guide wire proximally must had gone off and distally gone into the presumably underexpanded stented lumen and in this way the balloon dilatation caused the partial crush of the stents. The stent thrombosis itself after 1 month of the implantation during dual antiplatelet therapy retrospective also supports the possibility of undersizing and/or underdilatation of the stents. However the angiographies
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Int J Cardiovasc Imaging (2014) 30:1457–1459
Fig. 1 Left Coronary angiogram at admission because of the stent thrombosis (arrow). Right upper panel After recanalization by balloon angioplasty the stented segment exhibited some haziness
(arrow). Right lower panel Follow up angiography at 2 month: the blue line indicates the pull back of the OCT lens
Fig. 2 Upper panels OCT pull back after 2 months detected organized thrombi inside the crushed stent (on the longitudinal view the partially crushed stented segment can be measured to be 15 mm in
length). Lower panels 1 year later the repeated OCT proves complete endothelization on the same slices as above. A, B, C: the levels of slices are indicated also on the angiography on the Fig. 1 (red arrows)
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Int J Cardiovasc Imaging (2014) 30:1457–1459
did not provide exact information about this problem in the thin medial LAD. Intravascular imaging at the time of the index procedure could have been helped the proper choice of the stent size and the assessment of the stent apposition.
1459
The follow up investigation revealed that even this malpositioned stented segment exhibited full endothelization in this case. Conflict of interest
None.
123
IMAGES IN CV APPLICATIONS
OCT follow up of segmentally crushed stents in reopened coronary artery Bala´zs Tar • Istva´n Koo´s • Zsolt K} oszegi
Received: 24 June 2014 / Accepted: 21 July 2014 / Published online: 27 September 2014 Ó Springer Science+Business Media Dordrecht 2014
62 year old male patient had PCI by two DES implantation in October, 2012 (2.25/18 and 2.25/12 mm Resolute Integrity) because of subtotal occlusion on the medial part of the LAD distally to a very well developed diagonal branch. After one month he had a readmission with the symptoms of stent thrombosis (Fig. 1, left panel). During recanalization of the occluded stent by balloon angioplasty
Electronic supplementary material The online version of this article (doi:10.1007/s10554-014-0506-9) contains supplementary material, which is available to authorized users. B. Tar Z. K}oszegi Szabolcs – Szatma´r – Bereg County Hospitals and University Teaching Hospital, Nyı´regyha´za, Hungary I. Koo´s Borsod-Abau´j-Zemple´n County Hospital and University Teaching Hospital, Miskolc, Hungary Z. K}oszegi (&) Institute of Cardiology, University of Debrecen, Mo´ricz Zs. Krt. 22, 4004 Debrecen, Hungary e-mail: [email protected]
TIMI 3 flow was achieved, but slight haziness at the site of the stents raised the suspicion that the dilatation was performed partially outside the stent (Fig. 1, right upper panel). 2 months after the reintervention a follow up catheterization was performed in an OCT capable center. Coronary angiography showed patent LAD, while the OCT revealed that the stents had been crushed in 15 mm length to the one side of the vessel but the proximal and the distal part of the stented vessel segment showed good circumferential stent apposition. The crushed stent was filled by organized thrombi (Fig. 2, upper two left slices). After 1 year dual antiplatelet therapy another invasive investigation was decided. Functional assessment proved that the crushed stent caused only non-significant limitation in the hyperemic flow: FFR was determined to be 0.88. On the same time the repeated OCT investigation showed that the endoluminal surface of the crushed stent was completely endothelized (Figure 2, lower two left slices). These findings favored the discontinuation of the dual antiplatelet therapy. The further clinical follow up until now is uneventful. Our case shows the benefit of the OCT for clarifying the mechanism of the complication of the reintervention not detectable exactly by the angiogram: during the reopening of the occluded stents the guide wire proximally must had gone off and distally gone into the presumably underexpanded stented lumen and in this way the balloon dilatation caused the partial crush of the stents. The stent thrombosis itself after 1 month of the implantation during dual antiplatelet therapy retrospective also supports the possibility of undersizing and/or underdilatation of the stents. However the angiographies
123
1458
Int J Cardiovasc Imaging (2014) 30:1457–1459
Fig. 1 Left Coronary angiogram at admission because of the stent thrombosis (arrow). Right upper panel After recanalization by balloon angioplasty the stented segment exhibited some haziness
(arrow). Right lower panel Follow up angiography at 2 month: the blue line indicates the pull back of the OCT lens
Fig. 2 Upper panels OCT pull back after 2 months detected organized thrombi inside the crushed stent (on the longitudinal view the partially crushed stented segment can be measured to be 15 mm in
length). Lower panels 1 year later the repeated OCT proves complete endothelization on the same slices as above. A, B, C: the levels of slices are indicated also on the angiography on the Fig. 1 (red arrows)
123
Int J Cardiovasc Imaging (2014) 30:1457–1459
did not provide exact information about this problem in the thin medial LAD. Intravascular imaging at the time of the index procedure could have been helped the proper choice of the stent size and the assessment of the stent apposition.
1459
The follow up investigation revealed that even this malpositioned stented segment exhibited full endothelization in this case. Conflict of interest
None.
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