J INVASIVE CARDIOL 2019;31(8):E261-E262.
Key words: drug-eluting stent, long-term follow-up, stent thrombosis
54-year-old, non-diabetic, normotensive, non-smoker male presented with acute anterior-wall myocardial infarction (AWMI) at the emergency room in August 2007. He underwent primary angioplasty of an occluded proximal left anterior descending (LAD) (Figure 1A), and two overlapping 2.75 x 23 mm and 2.5 x 33 mm Cypher stents (Cordis Corporation) were deployed from ostial to distal LAD (Figure 1B). Intravascular imaging was not performed during the percutaneous coronary intervention (PCI). A follow-up angiogram after 4 years showed patent LAD stents (Figure 1C). In August 2018 (11 years after PCI), he again presented with acute AWMI despite continued dual-antiplatelet therapy. Coronary angiography revealed total occlusion of the proximal LAD (Figure 2A). The lesion was crossed with a Choice PT coronary guidewire (Boston Scientific) and sequentially dilated with 1.25 x 15 mm and 2.5 x 15 mm balloons (Figure 2B). Intravascular ultrasound revealed mild neointimal hyperplasia in the proximal-mid LAD and a markedly under-expanded and malapposed stent throughout its length from ostial to distal LAD (Figure 3; Video 1). The mean luminal diameter (MLD) and mean vessel diameter (MVD) of the proximal LAD (2.31 mm vs 4.14 mm) and distal LAD (2.10 mm vs 3.55 mm) showed a gross mismatch suggestive of malapposition (Figure 3). The entire stented segment was dilated with a 3.5 x 15 mm non-compliant balloon and the ostial-proximal LAD was additionally dilated with a 4 x 12 mm non-compliant balloon. TIMI-3 flow was achieved in the LAD (Figure 2C). Repeat IVUS revealed well-apposed stent struts, with mean cross-sectional area of 9.50 mm2 and MLD of 3.65 mm in the proximal LAD and cross-sectional area of 7.02 mm2 and MLD of 3.10 mm in the distal LAD (Figure 4; Video 2). As the result was optimal, no additional stent was deployed across the LAD. Patient was discharged on dual-antiplatelet therapy and was asymptomatic at 3-month follow-up exam.
From the Department of Cardiology, Post Graduate Institute of Medical Education & Research, Chandigarh, India.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted December 26, 2018.
Address for correspondence: Prof (Dr) Rajesh Vijayvergiya, MD, DM, FSCAI, FISES, FACC, Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Sector 12, Chandigarh – 160 012. India. Email email@example.com