CE: Namrta; JCM-D-14-00277; Total nos of Pages: 2;

JCM-D-14-00277

Images in cardiovascular medicine

Unusual stent fracture: diagnosis with optical coherence tomography Johan Bennett, Dries De Cock, Nick Hiltrop and Tom Adriaenssens We report an unusual case of new-generation drug-eluting stent fracture, diagnosed and managed with aid of optical coherence tomography J Cardiovasc Med 2014, 15:000–000

Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium Correspondence to Johan Bennett, MB, BCh, MD, University Hospitals Leuven, Leuven, Belgium E-mail: [email protected]

Keywords: optical coherence tomography, perforation, stent fracture

Received 7 May 2014 Revised 18 July 2014 Accepted 23 July 2014

A 69-year old man presented with a Non-ST elevation myocardial infarction 6 months following rotablation percutaneous coronary intervention (PCI) of the proximal left anterior descending coronary artery (LAD), which was complicated by a grade 2 coronary perforation treated with balloon sealing, pericardial drainage and, as there was complete resolution of contrast extravasation after

balloon sealing, stenting with a 2.5  33 mm Xience DES (panel a prestenting and panel b poststenting, right anterior oblique-cranial view). Coronary angiography revealed aneurysmal dilatation of the proximal LAD at the site of the initial perforation (panel C, a) and severe focal in-stent restenosis (ISR) in the mid-segment of the stent (panel c, arrowhead). Optical coherence

Figure 1

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DOI:10.2459/JCM.0000000000000200

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CE: Namrta; JCM-D-14-00277; Total nos of Pages: 2;

JCM-D-14-00277

2 Journal of Cardiovascular Medicine 2014, Vol 00 No 00

tomography (OCT) revealed underexpansion and mallaposition of struts in the ostial LAD (panel I, arrowheads), aneurysmal dilatation in the proximal LAD resulting in severely malapposed and uncovered struts (panel II, arrowheads), and slightly more distal a segment of severe focal ISR due to neointimal hyperplasia (panel III, ). Three-dimensional (3D) OCT reconstruction showed aneurysmal dilatation in the proximal LAD with a visible stent fracture just proximal to the focal ISR (panel d) and confirmed the presence of a type 4 complete stent fracture (panel e, arrow) with superior and distal displacement of the distal stent segment. PCI with implantation of a 3.0  14 mm Biomatrix DES was performed with angiographic success, and balloon dilation with a 4.5 non-compliant balloon was performed to partially correct the severe malapposition. Although often clinically silent and therefore underdiagnosed, stent fracture is a well known cause of stent failure, presenting as stent thrombosis or ISR.1 Extensive vessel wall trauma during the initial perforation may have provoked a strong inflammatory reaction and aneurysm formation. Several cases of stent fracture associated with aneurysms have been described, although the site of the stent failure was always within the aneurysm and, to the best of our knowledge, only in association with first-generation DES.2 We suggest that the aneurysmal dilatation and subsequent severe malapposition of the stent played an

important role, allowing abnormal motion and/or kinking of the stent within the aneurysm, leading to stent fracture, probably at some susceptible/hinge point further along the stent body. In the study by Chung et al.,1 stent fracture caused primarily focal ISR in more than 50% of patients. The mechanism of the restenosis in cases of stent fracture remains unclear, although there may be destruction of the strut in the fractured area, resulting in reduced local concentrations of drugs. Furthermore, continuous irritation by the fractured struts may also cause smooth muscle cell proliferation and inhibit re-endothelialization resulting in restenosis. In this case, the importance of using OCT in identifying mechanisms of stent failure and guiding management is clearly demonstrated.

Acknowledgements The authors report no financial relationships or conflicts of interest regarding the content herein.

References 1

2

Chung WS, Park CS, Seung KB, et al. The incidence and clinical impact of stent strut fractures developed after drug-eluting stent implantation. Int J Cardiol 2008; 125:325–331. Doi H, Maehara A, Mintz GS, et al. Classification and potential mechanisms of intravascular ultrasound patterns of stent fracture. Am J Cardiol 2009; 103:818–823.

Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.

Unusual stent fracture: diagnosis with optical coherence tomography.

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