Abstract 18411: Sirolimus Stents, Late Incomplete Stent Malapposition, in Stent Restenosis, Oh My- Glagov’s Phenomenon Revisited
A 52-year-old female with a history of hyperlipidemia and hypothyroidism presented with intermittent chest discomfort after minimal exertion. Her past medical history is significant for two mid left anterior descending artery (mLAD) Cypher sirolimus stents (2.5mm x 23mm, 2.5mm x 8mm) placed in 2008 when she presented with a NSTEMI. Her medications were aspirin, amlodipine, pitavastatin, synthroid and a multivitamin. Electrocardiogram demonstrated normal sinus rhythm. Physical exam was unremarkable and cardiac enzymes were negative. Baseline ejection fraction was 60% and there were no wall motion abnormalities during stress echocardiogram. Due to recurrent chest discomfort, CT angiography (CTA) was ordered which revealed two sequential stents with the proximal end of the first stent appearing outside the vessel lumen. Coronary angiography revealed ISR in the mLAD with contrast outside the proximal stent. Optical coherence tomography (OCT) was used which demonstrated positive remodeling, late incomplete stent malapposition (ISA) and ISR. Since studies have shown that the staining outside the sirolimus stent and ISA were associated with very late stent thrombosis, we decided that percutaneous coronary intervention (PCI) was not the ideal treatment. We opted for robotic coronary artery bypass graft (CABG) surgery with LIMA-LAD. The patient was discharged five days later without any complications. This case highlights the value of multi-modality imaging which revealed a Cypher related process despite a negative stress test. These observations led us to reason that we need a more permanent solution for treatment and therefore we referred the patient for CABG. It also raises important issues such as the duration of dual anti-platelet therapy in patients who have Cypher stents. Although Glagov’s phenomenon was originally described only for the case of arterial remodeling in response to growth of atherosclerotic plaques, our case emphasizes how a similar process can occur after PCI depending on the stent type. In conclusion, this case illustrates the limitations of angiography which is simply luminography, the complementary roles of CTA and OCT, and how multi-modality imaging can play a critical role in helping direct clinical-decision making.
Author Disclosures: J.E. Feig: None. R. Shimony: None. D.E. Soffer: None.
- © 2014 by American Heart Association, Inc.