A 74-year-old man with silent myocardial ischaemia underwent percutaneous coronary intervention to overlap a 3.0×38 mm everolimus-eluting stent (EES; XIENCE Alpine™, Abbott Vascular, Santa Clara, CA, USA) and a 2.5×16 mm everolimus-eluting platinum chromium stent (PtCr-EES; Promus PREMIER™, Boston Scientific Corp., Marlborough, MA, USA) in the mid-portion of the left anterior descending artery (LAD) (Moving image 1). Nine months after the stent implantation, the patient was readmitted to our hospital due to exertional chest pain. Coronary angiography (CAG) revealed significant restenosis at the mid-portion of the tortuous LAD segment (Moving image 2). Coronary computed tomography showed a distal stent fracture and shortening of the overlapping segment (Moving image 3). Optical coherence tomography (OCT) was also performed for the detailed examination. No significant luminal narrowing of the fractured segment was found (OCT, 3.97 mm2); whereas the minimum lumen area of the gaps between the two stented segments was 1.07 mm2 (OCT) (Moving image 4). A 3.0×12 mm PtCr-EES was successfully overlapped at the gap segment, from the proximal to the previously overlapped segment (Moving image 5). Follow-up CAG at 9 months after the second procedure resulted in no clinical events.
In the present case, the quantitative CAG analysis suggested that shortening of the overlapping segment and the gap between the two second-generation DESs might have occurred due to 1) straightening of the vessel curves after metallic stent implantation and 2) geometric changes caused by stent placement (Figure).
After the gap, caused by continuous stress during cardiac cycle, was created between the two second-generation DESs in the LAD, mechanical stress imposed on the stent edges would cause vessel wall injury and inflammation, characterised by the deposition of platelets and fibrin, as well as adhesions of circulating neutrophils and macrophages, which might lead to restenosis.
Previous studies reported that the PtCr-EESs with higher bending flexibility had greater fracture resistance against more severe angulation ranges than the other second-generation drug-eluting stents. In this case, the PtCr-EES was thus selected for significant restenosis at the gap between the two metal stents.
Supplementary Data
CAG after percutaneous coronary intervention and stenting of the LAD.
CAG showing significant restenosis at the mid-portion of the tortuous LAD segment.
Coronary computed tomography showing the distal stent fracture and shortening of overlapping segment.
OCT showing the distal stent fracture and the gaps between the two stented segments.
CAG after a PtCr-EES successfully overlapped the gap segment.
Acknowledgments
Conflict of interest statement
The authors have no conflicts of interest to declare.
Contributor Information
Nozomi Kotoku, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Yuki Ishibashi, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Yasuhiro Tanabe, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Akiyuki Kotoku, Division of Radiology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Hiroshi Yamazaki, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Shingo Kuwata, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Takanobu Mitarai, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Kazuaki Okuyama, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Kihei Yoneyama, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Takumi Higuma, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Tomoo Harada, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Yoshihiro J Akashi, Division of Cardiology, Department of Internal Medicine. St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.
Associated Data
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Supplementary Materials
CAG after percutaneous coronary intervention and stenting of the LAD.
CAG showing significant restenosis at the mid-portion of the tortuous LAD segment.
Coronary computed tomography showing the distal stent fracture and shortening of overlapping segment.
OCT showing the distal stent fracture and the gaps between the two stented segments.
CAG after a PtCr-EES successfully overlapped the gap segment.