Lesions at coronary divisions, either bifurcation or trifurcation, represent a challenging area in interventional cardiology. Indeed, it has been shown that percutaneous coronary intervention (PCI) in this anatomical setting using bare-metal stents (BMS) has a poor rate of procedural success and a high rate of restenosis.^1–3 More recently, the use of drug-eluting stents (DES), either sirolimus-eluting stents (SES) (Cypher™, Cordis Corp., Miami, Florida) or paclitaxel-eluting stents (PES) (Taxus^®, Boston Scientific Corp., Natick, Massachusetts), is associated with a lower event rate and reduction in restenosis compared with historical controls in this complex lesion subset.^4–7

Cardiac catheterization and PCI are usually performed by percutaneous access using the femoral artery. Following completion of the procedure, hemostasis is traditionally performed by manual compression, followed by 6 hours of bed rest. Hemostatic patches have been used as an adjunct for manual compression for management of femoral access site sheath removal.

Left anterior descending artery (LAD) lesions have been classically shown to be one of the independent predictors of adverse coronary events following percutaneous coronary interventions (PCI) compared with non-LAD lesions.^1–3 Recent studies utilizing sirolimus-eluting stents (SES), however, suggest a lower restenosis rate⁴ or a trend toward less target lesion revascularization⁵ in LADs. These different findings prompted us to perform a detailed analysis comparing vessel behavior following SES implantation. Thus, the aim of this study was to evaluate differential vessel response (LAD versus non-LAD) to SES implantation using serial intravascular ultrasound (IVUS).

Significant in-stent restenosis (ISR), i.e., intrastent neo-intimal proliferation following bare-metal stent (BMS) implantation, which determines an angiographic and/or clinically significant stenosis,¹ occurs with an incidence varying between 20–50% in real-life patients,² becoming however even more common in selected higher-risk subjects^3–4 and lesions,^5–6 e.g., diabetics, small vessels, or long lesions.^4,7 Indeed, BMS have targeted the underlying issues of elastic recoil and negative remodeling following percutaneous coronary intervention (PCI), however they did not reduce neointimal proliferation, but rather increased it.⁸

Drug-eluting stents (DES) have emerged as a novel technology in coronary revascularization. Ample evidence has shown that polymer-based DES effectively reduce in-stent restenosis and repeat revascularization after percutaneous coronary intervention (PCI).^1,2 However, there have been safety concerns over the current polymer-based DES on the possible delayed healing process and adverse reactions to the polymer when drug elution is completed, resulting in adverse events, including late stent thrombosis.^3–6 Therefore, DES with bioabsorbable drug/polymer composite coating are an attractive technology for improved safety and efficacy.

Acute coronary syndrome is one of the leading causes of morbidity and mortality in the United States, and afflicts 879,000 Americans each year.¹ Percutaneous treatment of acute coronary syndrome is a well-accepted remedy for relief of symptoms and reducing the extent of ischemic damage, but fails to alter the mortality rate.² Percutaneous stent placement has proven to be an effective modality to reduce obstructive coronary lesions.³ The Achilles’ heel of percutaneous stent placement is in-stent restenosis.

Bifurcation lesions are still technically challenging, even in the era of modern drug-eluting stents (DES).¹ Data on bare-metal stenting (BMS) did not demonstrate any advantages of the double-stent technique over single stenting because of a high incidence of restenosis in both the main vessel and the side branches. However, several kinds of double-stent techniques, including “T”, “V”, “Y”, “culotte” and “SKS (simultaneous kissing stents)” have been identified as being successful immediately after percutaneous coronary interventional (PCI) procedures.^2–5 DES dramatically decrease the in-stent restenosis rate after BMS.

With conventional equipment and methodology, certain anatomic conditions preclude the ability to pass a guidewire, balloon, or stent into the diseased target segment. These rare conditions include unusual coronary anatomy, chronic total occlusion, heavy vessel calcification, tortuosity and angulation, or ostial disease which prohibits deep engagement of the guiding catheter.

Case Presentation. A 52-year-old female was admitted in cardiogenic shock 4 days after multivessel stenting and closure of a grade 3 patent foramen ovale (PFO) with a 25 mm Amplatzer occluder. Diagnostic catheterization was performed under cardiac massage and demonstrated stent thrombosis of the stent in the mid left anterior descending coronary artery (LAD) and the posterolateral branch (PLB) of the right coronary artery (RCA) (Panel A – Arrows). Although TIMI 2 flow was rapidly restored in the LAD (Panel C – Top), the persistence of cardiogenic shock led us to implant a TandemHeart^® percutaneous transseptal left ventricular assist device (pVAD) (CardiacAssist, Inc., Pittsburgh, Pennsylvania). The PFO was crossed with a 6 Fr multipurpose catheter, passing underneath the right atrial disk of the Amplatzer occluder.

In the very interesting report¹ and editorial² published in the December 2006 issue of the Journal, the authors reported and commented on 13 patients who developed severe, diffuse coronary artery spasm after drug-eluting stent insertion. Five patients experienced diffuse multivessel spasm. Of these 5 patients, 2 died. The postmortem examination of one of the patients showed a few scattered mast cells in the adventitia of the left anterior descending coronary artery, possibly pointing to a hypersensitivity reaction to the stent components. The stent components currently in use should be considered as potential allergens capable of inducing the Kounis syndrome.³