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Very Early Progression of an In-Stent Calcified Nodule 2 Weeks After Drug-Eluting Stent Implantation in the Calcified Lesion.

ABSTRACT: In-stent calcified nodules (CNs) are one of the mechanisms of in-stent restenosis, but their underlying cause has not been elucidated. We report a case of a patient with early stent thrombosis due to an in-stent CN only 2 weeks after drug-eluting stent implantation. The fact that the in-stent CN was detected only 2 weeks after the initial percutaneous coronary intervention means that the underlying mechanism was the progression of the CN, indicating that in-stent CNs can occur even in the subacute phase. After percutaneous coronary intervention for a severe calcified lesion, very early progression of CNs can occur, and they require close follow-up and intensive antiplatelet therapy.

SUBMITTER: Higashino N

PROVIDER: S-EPMC9486871 | biostudies-literature | 2022 Sep

REPOSITORIES: biostudies-literature

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Very Early Progression of an In-Stent Calcified Nodule 2 Weeks After Drug-Eluting Stent Implantation in the Calcified Lesion.

Higashino Naoko N Ishihara Takayuki T Iida Osamu O Tsujimura Takuya T Hata Yosuke Y Toyoshima Taku T Nakao Sho S Mano Toshiaki T

CJC open 20220709 9

In-stent calcified nodules (CNs) are one of the mechanisms of in-stent restenosis, but their underlying cause has not been elucidated. We report a case of a patient with early stent thrombosis due to an in-stent CN only 2 weeks after drug-eluting stent implantation. The fact that the in-stent CN was detected only 2 weeks after the initial percutaneous coronary intervention means that the underlying mechanism was the progression of the CN, indicating that in-stent CNs can occur even in the subacu ...[more]

PMID: 36148260

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Project description:BackgroundCalcified nodule (CN) is a phenotypic feature of calcified plaques which causes acute coronary syndrome (ACS). Recent studies reported that culprit lesions harboring CN has been shown to increase a risk of repeat revascularization after percutaneous coronary intervention (PCI) with the implantation of newer-generation drug-eluting stent (DES) or debulking device. Mechanistically, a re-protrusion of CN into the lumen has been considered as an important cause associated with repeat revascularization after PCI. These observations suggest the need for additional therapeutic approach to mitigate a risk of repeat revascularization at CN lesions. Here we report a case who received the implantation of one covered stent due to coronary artery perforation after stent implantation at coronary lesion exhibiting CN. This case is unique in terms of preventing restenosis by using covered stent which could physically hinder protrusion of CN through the stent strut.Case descriptionA 79-year-old man presented to the emergency department with his prolonged chest pain. Although he had a history of hypertension and adrenal hypertrophy, he was not taking any medication prior to his admission. He was diagnosed as ST-segment elevation myocardial infarction. Emergent coronary angiography revealed one severe stenosis in the middle segment of his right coronary artery (RCA). Primary PCI was performed under the guidance of intravascular ultrasound (IVUS) imaging. IVUS imaging prior to PCI revealed a protruding shape of calcification and its irregular surface at his culprit lesion, suggesting the presence of a CN. Following one DES implantation, coronary artery perforation occurred at the segment receiving DES implantation. We implanted one covered stent for the coronary artery perforation. This procedure resulted in successfully sealing coronary artery perforation. Seven months later, follow-up coronary angiography and optical coherence tomography (OCT) imaging were conducted to evaluate his RCA. Any in-stent restenosis (ISR) was not observed. Furthermore, OCT imaging elucidated a small amount of neointimal proliferation without any re-protruding feature of CN through the segment receiving a covered stent. Of note, he did not experience any clinically-driven target lesion revascularization (TLR) for 2 years after PCI.ConclusionsOur case indicates the use of covered stent as an effective approach to physically hinder the re-protrusion of calcification tissues into the lumen, potentially mitigating a risk of ISR.

Project description:AimsIn-stent chronic total occlusion (IS-CTO) represents a unique challenge for percutaneous coronary intervention. Whether the optimal treatment for IS-CTO is angioplasty with paclitaxel-coated balloons (PCBs) or repeat stenting with drug-eluting stents (DESs) is unclear. We aimed to evaluate the long-term clinical outcome of PCB angioplasty and DES repeat stenting for DES IS-CTO.MethodsWe retrospectively included patients with DES IS-CTO who underwent successful PCB angioplasty or DES repeat stenting from January 2016 to December 2019. The primary endpoints were major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, and target lesion revascularization (TLR). Cox proportional hazards model was performed to compare the risk of MACEs between PCB angioplasty and DES repeat stenting, and to further explore the prognostic factors of patients with DES IS-CTO.ResultsA total of 214 patients with DES IS-CTO were enrolled: 78 patients (36.4%) treated with PCB and 136 patients (63.6%) treated with DES respectively. The median follow-up was 1160 days, and MACEs were observed in 28.2% of patients with PCB angioplasty versus 26.5% of patients with DES repeat stenting (P = 0.784), mainly driven by TLR (21.8% vs. 19.9%, P = 0.735). There was no significant difference in the risk of MACEs between the PCB group and the DES group (hazard ratio [HR] 1.25, 95% confidence interval [CI] 0.64-2.46, P = 0.512). Multivariate Cox analysis revealed that chronic kidney disease and ≥ 3 stent layers in the lesion were independent predictors of MACEs, while switching to another antiproliferative drug was an independent protective factor (all P < 0.05).ConclusionsPCB angioplasty was an effective alternative treatment strategy for DES IS-CTO, which had similar long-term outcomes to DES repeat stenting in contemporary practice, but both were accompanied by a high rate of long-term MACEs. Improving the poor prognosis of patients with DES IS-CTO remains a challenge.

Dataset Information

Very Early Progression of an In-Stent Calcified Nodule 2 Weeks After Drug-Eluting Stent Implantation in the Calcified Lesion.

Publications

Very Early Progression of an In-Stent Calcified Nodule 2 Weeks After Drug-Eluting Stent Implantation in the Calcified Lesion.

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