Very Late Stent Thrombosis by Angiography. A Case of Atherosclerosis Progression by OCT

The progressive nature of coronary atherosclerotic disease is often neglected in patients submitted to percutaneous coronary intervention. Very late (> 1 year) myocardial infarctions affecting the treated myocardial territory are usually attributed to device related complications. We report the case of a patient with acute inferior wall ST-elevation myocardial infarction, who had a thrombotic occlusion of a bare-metal stent implanted 8 years before. Despite the angiographic diagnosis of very late stent thrombosis, optical coherence tomography revealed that the acute myocardial infarction was caused by rupture of an atherosclerotic plaque outside of the previously stented segment.

Myocardial infarction; Percutaneous coronary intervention; Stents; Tomography, optical coherence; Coronary thrombosis

Authorship

Antonio de Castro Filho

Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, BrazilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP, BrazilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil

Daniel Chamié

Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, BrazilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP, BrazilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil

Alexandre Abizaid

Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, BrazilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP, BrazilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

SCIMAGO INSTITUTIONS RANKINGS

Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, BrazilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP, BrazilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil

Figures

Figures (5)

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Figure 1
Electrocardiogram at admission. ST-segment elevation is observed in the inferior, lateral, and posterior walls

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Figure 2
Coronary angiography. Left main coronary artery with no significant obstructions (A, B, and C). Right coronary artery shows a thrombus inside the stent positioned in the distal third (D). Left ventriculography (E and F) show moderate basal and mid-inferior wall hypokinesis. Dotted lines indicate the sites of previously implanted stents

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Figure 3
Optical coherence tomography. The central panels show the right coronary artery before (A) and after (B) flow restoration. Thrombi removed during thromboaspiration (C). The stent in the distal third showed struts with homogeneous tissue coverage. The stent and lumen areas, indicated by red and blue contours, define the neointimal tissue with normal optical appearance (1). After the stent distal edge, stenotic fibrotic plaque can be observed (2). At the “shoulder” of the stenosis, a predominantly lipid plaque can be observed, with fibrous cap rupture and residual thrombus (3). The following ectatic segment is the vessel region with normal appearance (4). Distal to this segment, a lipid plaque, with multiple fibrous caprupture sites, can be observed (5-7). At the bifurcation, there is large amount of thrombus (8), followed by eccentric fibrotic plaque (9). The proximal part of the posterior descending branch shows concentric intimal thickening (10).

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Figure 4
Percutaneous coronary intervention. A 2.5 × 18 mm stent was implanted in the distal segment (A). This stent was post-dilated in its proximal part with a 3.0 × 12 mm noncompliant balloon (B). After the guide wires were repositioned, the posterior ventricular branch ostium was post-dilated with a 2.0 × 8 mm non-compliant balloon (C), followed by simultaneous balloon inflation in the posterior descending and posterior ventricular branches (D). Another 4.0 × 30 mm stent was implanted proximally, with minimal overlap with the previously implanted stent (yellow line) and the existing stent (white line) (E). Focal stent post-dilation, under the ectatic region, was performed with a 12 × 5.0 mm noncompliant balloon (F).

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Figure 5
Control angiography and optical coherence tomography. The previously implanted stents (white lines) and the newly implanted stents (yellow and green lines) show minimal overlap of the struts and complete segmental coverage. Panel 1 shows the location of the overlapping struts with the previous stent (asterisks). Thrombotic material prolapse can be observed, which explains the hypertransparent image on angiography (2). The focal post-dilation with a 5.0 × 12 mm balloon showed appropriate expansion and strut apposition in the ectatic segment (3 and 4). Outside the ectatic segment, the stent accompanies the size of the vessel (5). Next to the bifurcation, another point of thrombotic material prolapse is observed (6). Adequate stent expansion and apposition were attained at the bifurcation (7) and at its distal edge in the proximal third of the posterior descending branch (8)

Figure 1 Electrocardiogram at admission. ST-segment elevation is observed in the inferior, lateral, and posterior walls

Figure 2 Coronary angiography. Left main coronary artery with no significant obstructions (A, B, and C). Right coronary artery shows a thrombus inside the stent positioned in the distal third (D). Left ventriculography (E and F) show moderate basal and mid-inferior wall hypokinesis. Dotted lines indicate the sites of previously implanted stents

Figure 3 Optical coherence tomography. The central panels show the right coronary artery before (A) and after (B) flow restoration. Thrombi removed during thromboaspiration (C). The stent in the distal third showed struts with homogeneous tissue coverage. The stent and lumen areas, indicated by red and blue contours, define the neointimal tissue with normal optical appearance (1). After the stent distal edge, stenotic fibrotic plaque can be observed (2). At the “shoulder” of the stenosis, a predominantly lipid plaque can be observed, with fibrous cap rupture and residual thrombus (3). The following ectatic segment is the vessel region with normal appearance (4). Distal to this segment, a lipid plaque, with multiple fibrous caprupture sites, can be observed (5-7). At the bifurcation, there is large amount of thrombus (8), followed by eccentric fibrotic plaque (9). The proximal part of the posterior descending branch shows concentric intimal thickening (10).

Figure 4 Percutaneous coronary intervention. A 2.5 × 18 mm stent was implanted in the distal segment (A). This stent was post-dilated in its proximal part with a 3.0 × 12 mm noncompliant balloon (B). After the guide wires were repositioned, the posterior ventricular branch ostium was post-dilated with a 2.0 × 8 mm non-compliant balloon (C), followed by simultaneous balloon inflation in the posterior descending and posterior ventricular branches (D). Another 4.0 × 30 mm stent was implanted proximally, with minimal overlap with the previously implanted stent (yellow line) and the existing stent (white line) (E). Focal stent post-dilation, under the ectatic region, was performed with a 12 × 5.0 mm noncompliant balloon (F).

Figure 5 Control angiography and optical coherence tomography. The previously implanted stents (white lines) and the newly implanted stents (yellow and green lines) show minimal overlap of the struts and complete segmental coverage. Panel 1 shows the location of the overlapping struts with the previous stent (asterisks). Thrombotic material prolapse can be observed, which explains the hypertransparent image on angiography (2). The focal post-dilation with a 5.0 × 12 mm balloon showed appropriate expansion and strut apposition in the ectatic segment (3 and 4). Outside the ectatic segment, the stent accompanies the size of the vessel (5). Next to the bifurcation, another point of thrombotic material prolapse is observed (6). Adequate stent expansion and apposition were attained at the bifurcation (7) and at its distal edge in the proximal third of the posterior descending branch (8)

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Very Late Stent Thrombosis by Angiography. A Case of Atherosclerosis Progression by OCT

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[1] CONFLICTS OF INTEREST

The authors declare no conflicts of interest.