Covered-Stent Treatment of Coronary Aneurysm after Drug-Eluting Stent Placement: Case Report and Literature Review

Most commonly, coronary artery aneurysms are secondary to atherosclerosis, but cases have been reported in patients who have vasculitis or tissue disorders, and in patients who have undergone interventional procedures. However, over the past few years, an increasing number of cases of coronary artery aneurysms after drug-eluting stent implantation have been reported. The exact mechanism is unknown. Experimental animal studies have shown that both the active drug and the polymer coating, under certain circumstances, might cause progressive luminal dilation, positive vascular remodeling, and aneurysmal formation. Complications like rupture, thrombosis, embolization, myocardial infarction, and even sudden death have been reported. Treatment options vary from aggressive surgical ligation of the aneurysm, in union with distal bypass surgery, to percutaneous implantation of a covered stent or conservative medical management with continued antiplatelet therapy. Currently, there is no consensus on an ideal approach to treating coronary artery aneurysm after drug-eluting stent implantation. Polytetrafluoroethylene-covered stents, easy and rapid to deploy, have emerged as a newer option. We report a case of coronary artery aneurysm at the site of a previous drug-eluting stent. The lesion was successfully treated with a polytetrafluoroethylene-covered stent.Key words: Blood vessel prosthesis, coronary aneurysm/etiology/therapy, coronary disease/therapy, covered stents, dilatation, pathologic, drug delivery systems/adverse effects, drug-eluting stents/adverse effects, polytetrafluoroethylene, postoperative complications, sirolimus/administration & dosage, stents/adverse effectsAneurysmal dilation of the coronary arteries was first described by Bougon in 1812.¹ Most commonly, coronary artery aneurysms are secondary to atherosclerosis,² but cases have been reported in patients who have vasculitis (Kawasaki syndrome,³ for example) or tissue disorders (Ehlers-Danlos⁴ or Marfan syndrome,⁵ for example), and in patients who have undergone interventional procedures.^6,7 Over the past few years, an increasing number of case reports have described a growing incidence of coronary artery aneurysms after drug-eluting stent (DES) implantation.^8–11 Since 2003, when the U.S. Food and Drug Administration approved the 1st such stent, DESs have unequivocally demonstrated their superiority to bare-metal stents in regard to in-stent restenosis.^9–12 Nevertheless, safety concerns brought up from time to time—especially regarding the increased risk of late stent thrombosis¹³—have raised questions about the long-term safety of DES implantations.The exact mechanism of coronary artery aneurysmal formation after DES placement is unknown. Complications such as rupture,¹⁴ thrombosis,¹⁵ distal embolization,¹⁶ myocardial infarction,¹⁷ and even sudden death¹⁸ have been reported. Here we report a case of coronary artery aneurysm at the site of DES implantation, which we successfully treated with a polytetrafluoroethylene (PTFE)-covered stent. In addition, we present a review of the literature on the use of PTFE-covered stents in the repair of coronary artery aneurysms that have formed at the site of DES implantation.     

合理看待药物洗脱支架晚期血栓问题

冠状动脉支架现广泛应用于冠心病的介入治疗中。支架内血栓是金属裸支架和药物洗脱支架的一个并发症,可导致心肌梗死或死亡。最近,药物洗脱支架引起晚期支架内血栓的问题引起人们的广泛关注。支架血栓的危险因素包括操作因素(如支架贴壁不良、置入支架的数目、支架长度及夹层)、患者及病变因素、过早停用抗血小板药物以及支架释放的药物使内皮延迟愈合等。现对支架晚期血栓的概念、发生的危险因素、防治措施等进行探讨。     

药物支架时代的支架血栓问题

药物洗脱支架具有显著降低支架内再狭窄发生率的作用,显著降低冠状动脉粥样硬化性心脏病病死率及减少血管急性闭塞发生。药物支架时代的支架内血栓一直是冠状动脉介入手术治疗冠状动脉粥样硬化性心脏病的当前研究热点,其一旦发生,导致严重后果。现就当前药物支架时代支架内血栓的问题研究进展进行综述。     

Coronary Stent Infections: A Case Report and Literature Review

Although rare, coronary artery stent infections are associated with a high mortality rate. Since the introduction of coronary stents in 1987, only 16 cases of infection have been reported. We report a new case in a 66-year-old woman who had undergone a difficult percutaneous coronary intervention procedure, during which 3 overlapping stents were implanted in the mid portion of the right coronary artery. Twenty-two days after the procedure, the patient died. Autopsy revealed the cause of death to be pericardial tamponade due to rupture of the right ventricular myocardium. The stented portion of the right coronary artery was enveloped by an abscess, and purulent material completely occluded the stents. Cultures of the myocardium were positive for methicillin-resistant Staphylococcus aureus. We conducted a review of the literature on coronary artery stent infections. Data suggest that early-onset infections (<10 days after stent implantation) are potentially amenable to medical therapy alone, but late-onset infections (≥10 days after implantation) or major complications necessitate combined surgical and medical therapy. Medical therapy consists of broad-spectrum antibiotics. Surgical intervention includes stent removal if possible, and abscess drainage or perforation repair when indicated.Key words: Blood vessel prosthesis implantation/adverse effects, coronary stent infections, prosthesis-related infections/complications/diagnosis/therapy, stents/adverse effects, Staphylococcus aureusCoronary artery stents have been in use for more than 2 decades. Stent infections are rare, hard to treat, and potentially devastating. Our treatment of a patient with a coronary stent abscess prompted us to review the literature. From our experience and the evaluation of previously reported cases,^1–14 we propose an approach for diagnosing and treating these infections.     

药物支架晚期血栓

药物支架很大程度上解决了支架内再狭窄的问题。但最近药物支架晚期血栓的问题倍受关注。现就可能导致药物支架晚期血栓的因素及支架的发展前景做一简要综述。     

Very Late Stent Thrombosis 11 Years after Implantation of a Drug-Eluting Stent

Very late stent thrombosis is an infrequent yet potentially fatal complication associated with drug-eluting stents. We report the case of an 88-year-old man who sustained an ST-segment-elevation myocardial infarction 11 years after initial sirolimus-eluting stent implantation. Optical coherence tomograms of the lesion showed that the focal incomplete endothelialization of the stent struts was the likely cause; neointimal formation, neoatherosclerosis, and late stent malapposition might also have contributed.To our knowledge, this is the longest reported intervening period between stent insertion and the development of an acute coronary event secondary to very late stent thrombosis. The associated prognostic and therapeutic implications are considerable, because they illuminate the uncertainties surrounding the optimal duration of antiplatelet therapy in patients who have drug-eluting stents. Clinicians face challenges in treating these patients, particularly when competing medical demands necessitate the discontinuation of antiplatelet therapy. In addition to the patient''s case, we discuss factors that can contribute to very late stent thrombosis.     

药物洗脱支架与晚期、极晚期支架血栓

第一代药物洗脱支架在显著降低再狭窄率的同时,也带来了支架血栓尤其是晚期、极晚期支架血栓这一棘手问题.晚期、极晚期支架血栓虽然发生率较低,但一旦发生往往带来灾难性后果.晚期、极晚期支架血栓的发生机制包括血管再内皮化延迟、多聚物过敏反应、支架晚期贴壁不良及新生动脉粥样硬化斑块破裂等.第二代和第三代药物洗脱支架在安全性上可能优于第一代.生物全降解支架代表了药物洗脱支架的发展方向,有望从根本上解决药物洗脱支架的晚期和极晚期支架血栓问题.现对近年来药物洗脱支架晚期及极晚期支架血栓的发生机制及新一代药物洗脱支架的研究进展做一综述.     

Primary Aldosteronism Presenting with Hypertension Five Days after Delivery: A Case Report and Literature Review

A 35-year-old Japanese woman with no history of hypertension developed hypertension 5 days after normal delivery. Endocrinological and radiological examinations indicated primary aldosteronism (PA) and a 1.4-cm left adrenal tumor. The patient underwent laparoscopic adrenalectomy, and a diagnosis of aldosterone-producing adenoma was confirmed immunohistochemically. Her plasma aldosterone concentration and blood pressure normalized. Cases of PA presenting with hypertension in the postpartum period have been reported. This case suggests that PA should be considered in women with postpartum hypertension, especially in those with blood pressure that suddenly increases shortly after delivery, even if they were normotensive before and throughout pregnancy.     

冠状动脉支架内血栓与药物洗脱支架的安全性

最近,药物洗脱支架的安全性问题引起了人们的广泛关注。目前资料表明药物洗脱支架与金属裸支架相比并不引起更多的早、晚期支架内血栓发生,但极晚期支架内血栓形成的风险增加。药物洗脱支架明显降低支架内再狭窄的发生和靶病变的再次血运重建率,其有效性仍优于金属裸支架,尤其对于糖尿病等再狭窄高危患者。根据患者的临床具体情况合理选择支架非常重要。现综述冠状动脉支架内血栓与药物洗脱支架安全性的研究进展。     

Subclavian Vein Thrombosis: A Case Report and Review of the Literature

Described herein is the case of a 55-year-old woman who was admitted to our hospital because of neck discomfort and left-arm edema. Our patient was diagnosed to have primary left subclavian vein thrombosis. The prevalence of hypercoagulable states in patients with upper-extremity, idiopathic, deep-vein thrombosis is discussed and reviewed.     

Mechanical Prosthetic Valve Thrombosis: Case Report and Review of the Literature

Mechanical prosthetic valve thrombosis is a life-threatening complication necessitating immediate intervention. The presenting signs and symptoms of this illness are somewhat variable, but physical examination and transesophageal echocardiography enable rapid diagnosis. To avoid catastrophic complications, valve replacement or debridement, or thrombolysis in the correct setting, must be performed without delay. It is not entirely clear which therapy is superior. For any given patient, the risks of thrombolytic therapy, including bleeding, systemic embolism, and failure to restore valvular function, must be weighed against the risks of surgical intervention. Once the decision is made to operate, the choice of valve replacement versus debridement is one best made intraoperatively, upon visual inspection of the valve apparatus. Despite aggressive therapy, morbidity and mortality from prosthetic valve thrombosis and its treatment are not trivial. Fortunately, with current prosthetic devices and aggressive prophylactic anticoagulation, the incidence of prosthetic valve thrombosis remains low. Antiplatelet therapy may offer additional benefit to patients being prophylaxed with warfarin. This report details the case of a woman with aortic and mitral prosthetic valves who presented with heart failure and evidence of severe aortic prosthetic dysfunction after a period of suboptimal anticoagulation. She successfully underwent debridement of the mitral prosthesis and replacement of the aortic valve. The relevant literature is reviewed.     

药物洗脱支架:如何平衡再狭窄减少与支架内血栓

药物先脱支架通过抑制平滑肌细胞的增殖减少了支架内再狭窄,但也因此而出现了支架内血栓的不良反应,现综述其临床益处及局限性,并分析其导致支架内血栓的相习因素.     

Drug-Eluting Coronary Stent Very Late Thrombosis Revisited

Compared to bare-metal stents (BMS), drug-eluting stents (DES) provide a significant additional reduction in restenosis rates and the need for coronary reinterventions. However, compared to BMS, the risk of very late stent thrombosis (ST) appears to be marginally higher accounting for 0.2-0.6% annual incidence for up to 3 years and possibly even longer following implantation. Risk reduction strategies include meticulous implantation technique, identification of patients with increased thrombotic risk, exclusion of patients scheduled in short term for major elective surgeries, and extended dual antithrombotic treatment for a minimum of 12 months. Future risk avoidance strategies are briefly reviewed and commented.     

血管内超声在冠状动脉药物洗脱支架晚期血栓研究中的应用

药物洗脱支架与金属裸支架相比,减少了再狭窄的发生率,但其长期安全性却引起了人们的注意。支架置入30 d以后出现的晚期支架内血栓问题成为目前介入心脏病学的研究热点。晚期支架内血栓发生率低,但一旦发生后果严重。有研究显示其发生的原因可能包括动脉的延迟愈合、动脉瘤形成及支架贴壁不良等。现就血管内超声在冠状动脉药物洗脱支架晚期血栓研究中的应用进展做一评述。     

药物洗脱支架时代支架血栓的研究进展

冠心病的介入治疗已广泛应用于临床.药物洗脱支架作为新技术,被多项临床研究证实其安全性和降低再狭窄率的有效性.药物洗脱支架兴起后短短的几年内,在冠心病的介入治疗中发挥了巨大作用.随着其在临床应用的普及和应用范围的推广,研究发现支架血栓尤其是晚期及极晚期支架有增加的趋势.但是就支架血栓问题,各研究报道不一,临床意义尚不明确,现根据最新研究文献作一综述.     

Fracture of a Popliteal Nitinol Stent: Case Report and Review of the Literature

IntroductionEndovascular stenting of popliteal occlusion is a common procedure in vascular practice.Stent fractures normally cause restenosis or occlusion of the arterial segment treated.ReportWe present a case of a large aneurysm of the popliteal artery that was observed 14 months after popliteal stenting with self-expandable nitinol stent.We describe the endovascular approach that has been used to solve this severe complication.DiscussionStent fractures are often a hidden complication of femoro-popliteal stenting that can be associated with important disease; a careful follow-up and prompt management in expert hands in the majority of the cases lead to a favourable resolution.     

High-dose-infliximab-associated Cerebral Venous Sinus Thrombosis: A Case Report and Review of the Literature

A 28-year-old woman experienced severe headache and right homonymous hemianopia after receiving high-dose infliximab for Crohn''s disease. Computed tomography showed hemorrhagic infarction in the left temporal and parietal lobes. An angiogram revealed left transverse to sigmoid sinus occlusion and a stagnated Labbe vein. The patient was treated surgically and achieved a good outcome. Inflammatory bowel diseases are known to accompany venous and arterial thrombosis in 1-2% of cases. Recently, infliximab has been suggested to increase this possibility. A case of Crohn''s disease presenting with cerebral sinus thrombosis in the remission period during long-term/high-dose use of infliximab is presented. In addition, infliximab-associated thrombosis cases were reviewed.