Acute ST-elevation myocardial infarction 6 years following a sirolimus-eluting stent secondary to complete stent fracture

With increasing coronary interventions, coronary stent fracture following implantation of drug-eluting stents is being commonly recognized. Though isolated strut fractures are often only incidental findings, more severe forms of stent fracture with complete transection have adverse clinical outcomes. Most such cases are reported within several months following the index angioplasty. We report an unusual presentation of late stent fracture following a sirolimus-eluting stent, presenting with acute myocardial infarction 6 years after the initial stent implantation. The various mechanisms underlying fracture of drug-eluting stents are reviewed. Because no known mechanisms were noted in our case, unknown factors may also play a role in the genesis of stent fracture. Clinicians need to be aware that such complications may present rarely, extremely late after the index procedure as an acute myocardial infarction.     

Frequency of stent fracture as a cause of coronary restenosis after sirolimus-eluting stent implantation

Stent fracture (SF) was suggested as a cause of restenosis after sirolimus-eluting stent (SES) implantation. This study was performed to evaluate the incidence and characteristics of SF to determine its contribution to restenosis in patients with in-stent restenosis (ISR) after SES implantation. From May 2003 to February 2006, SESs were used for percutaneous coronary intervention in 868 patients with 1,109 coronary narrowings. Follow-up coronary angiography was performed in 366 patients (42%), and 26 ISR lesions were observed. These patients were enrolled in this study. SF was divided into 3 types as avulsion, collapse, and partial based on the findings of fluoroscopy, coronary angiography, and intravascular ultrasound study. Of 26 patients with ISR lesions, SF was identified in 10. SF types were avulsion (5 patients), collapse (2 patients), and partial (3 patients). SF was identified at the midshaft (7 patients) and overlap sites (3 patients) of stents. SF was not observed in the 30 patients with ISR after bare-metal Bx Velocity stent implantation. Four patients with SF were treated with paclitaxel-eluting stents. In conclusion, SF is 1 of the leading causes of ISR after SES implantation. Careful fluoroscopic examination is necessary at the time of follow-up angiography to identify this problem.     

Acute myocardial infarction caused by rupture of minimal intrastent intimal hyperplasia after implantation of bare-metal stent

Although instent restenosis after implantation of bare-metal stent has been manifested as a benign clinical presentation, some studies reported that acute coronary syndrome could be developed as a result of ruptured ISR. However, little evidence exists concerning acuity of minimal to moderate stenotic lesion that is not severe enough to warrant repeat percutaneous coronary intervention. Recently, we experienced a case of acute myocardial infarction caused by rupture of minimal instent intimal hyperplasia after implantation of bare-metal stent. Our case showed that minimal stenotic lesion after implantation of bare-metal stent could be a nidus for subsequent thrombus formation like instent restenotic lesion.     

Incidence and clinical impact of coronary stent fracture after sirolimus-eluting stent implantation.

BACKGROUND: Stent fracture is one of the possible causes of restenosis after sirolimus-eluting stents (SES) implantation. The aim of our study was to evaluate the prevalence and clinical impact of coronary stent fracture after SES implantation. METHODS: From our prospective institutional database, 280 patients were treated solely with SES from August 2004 to June 2005. Among the 280 patients, 256 patients with a total of 307 lesions underwent follow-up angiography on an average of 240 days after the procedure. RESULTS: Stent fractures were observed in eight (2.6%) lesions. Of the eight lesions with stent fracture, five were located in the right coronary artery (RCA), two in the saphenous vein (SV) graft, and one in the left anterior descending coronary artery. The stent fractures were all in the locations that served as hinges during vessel movement in the cardiac contraction cycle. Seven of the eight stent fractures were adjacent to the edge of previously implanted or overlapped stent. Significant multivariate predictors of stent fracture were SV graft location (Odds ratio 35.88; 95% confidence interval 2.73-471.6, P = 0.006), implanted stent length (Odds ratio 1.04; 95% confidence interval 1.01-1.07, P = 0.02), and RCA location (Odds ratio 10.00; 95% confidence interval 1.11-89.67, P = 0.04). In-stent binary restenosis rate was 37.5% and target lesion repeat revascularization rate was 50.0% in patients with stent fracture. CONCLUSIONS: Stent fracture was likely to be affected by mechanical stress provoked by rigid structures and hinge points. Stent fracture might be associated with the high incidence of target lesion revascularization.     

Late stent thrombosis after implantation of a sirolimus-eluting stent.

Late stent thrombosis in the era of routine high-pressure stent deployment and combined antiplatelet therapy with thienopyridines and aspirin has become a rare but feared complication. We describe a patient with acute myocardial infarction due to late stent thrombosis 6 weeks after deployment of a sirolimus-eluting stent and 2 weeks after the discontinuation of clopidogrel. This is the first report of late thrombosis of a sirolimus-eluting stent.     

Acute myocardial infarction as a consequence of anaphylactic reaction after administration of urovision

The case of 52-year old patient was presented who developed urticaria and strong anginal pain after intravenous administration of uropoline. On the basis of typical clinical picture, electrocardiographical and biochemical changes acute myocardial infarction was recognised. It is thought to have developed as the consequence of anaphylactic reaction following intravenous administration of x-rays contrast substance.     

急性心肌梗死患者药物支架置入术后支架贴壁不良特征及对预后的影响

目的探讨急性心肌梗死患者置入西罗莫司药物洗脱支架后,支架贴壁不良(ISA)的特征及ISA对临床预后的影响。方法选择197例冠心病(300处病变)患者置入西罗莫司药物洗脱支架。根据临床表现分为急性心肌梗死组(67例,117处病变),不稳定性心绞痛组(73例,99处病变),稳定性心绞痛组(57例,84处病变)。术后1年血管造影时利用血管内超声观察各组患者支架置入处ISA的发生率和特征.根据ISA造声情况又分为贴壁不良患者和非贴壁不良患者.并在复查后1年临床随访主要不良心脏事件(包括靶病变再次血运重建,非致命性心肌梗死,心源性死亡和全因死亡)。结果急性心肌梗死组支架置入后,有17例患者(17处病变.25.4%)在1年随访检查时存在ISA,明显高于不稳定性心绞痛组(7例患者,7处病变,9.6%)和稳定性心绞痛组[(4例患者,4处病变,7.0%),P=0.005]。多因素回归分析显示,病变长度(OR=1.068,P=0.037)、急性心肌梗死(OR=2.399,P=0.031)和非糖尿病(OR=6.472.P=0.013)是晚期ISA的独立危险因素。对ISA患者1年临床随访显示,ISA患者与非ISA患者主要心脏不良事件无统计学差异(7.1% vs 2.4%,P=0.203)。结论急性心肌梗死患者置入西罗莫司药物洗脱支架后ISA的发生率较高。支架置入后晚期ISA与临床事件的关系仍需进一步研究。     

Late catch-up phenomenon associated with stent fracture after sirolimus-eluting stent implantation: incidence and outcome

Objective: To examine the long‐term outcome of the stent fracture (SF) and the potential predictive factors contributing to in‐stent restenosis (ISR) in the fractured stent. Background: The SF is thought to be a higher risk of ISR in drug‐eluting stent, although SF does not always develop ISR. Methods: The consecutive 1,228 de novo lesions in 1,079 patients who underwent sirolimus‐eluting stents implantation and assessed by 8 months follow‐up coronary angiography were retrospectively analyzed. Results: One hundred and seventeen SFs (9.5%) were identified in 100 patients and 22 (18.8%) SFs revealed ISR at the first follow‐up. In addition, 16 (13.7%) developed new ISRs from 95 residual SFs without ISR prior to the second follow‐up. Overall, 38 (32.5%) of all 117 SFs developed ISR, and 16 (42.1%) of 38 SFs occurred in a late phase beyond the first 8 months follow‐up. A higher risk of ISR in the SF site was associated with the chronic total occlusion (ISR vs. no ISR: 34.2% vs. 16.5%, P = 0.0304), calcified lesions (55.3% vs. 34.2%, P = 0.0299), and correspondence 89.5% versus 43.0%, P < 0.0001 (SF site occurring at the original target lesion site) in the univariate analysis. The correspondence was identified as the only strong predictive factor for ISR at the SF site according to a multivariate logistic regression analysis (odds ratio 12.6, 95% confidence interval 3.82–53.5, P < 0.0001). Conclusions: SF occurring at the site of the original target lesion was a strong independent predictor of ISR. This indicates the need for a careful, long‐term follow‐up in those situations, even when no significant ISR is initially detected. (J Interven Cardiol 2011;24:165–171)     

Acute myocardial infarction caused by thrombotic occlusion at a stent site two years after conventional stent implantation

Two cases of acute myocardial infarction caused by thrombotic occlusion at the conventional stented site two years after stenting are described. Late thrombotic stent occlusion may be caused by atherosclerotic regression, sustained inflammatory reaction, and inhibition of proliferation of neointima. Cardiologists must be aware of the potential for late thrombosis following even conventional stent implantation.     

Acute myocardial infarction due to late stent thrombosis seventeen months after stent implantation: a case report

A 59-year-old man with acute myocardial infarction underwent successful stent implantation for proximal left anterior descending coronary artery occlusion. Antiplatelet therapy with 100 mg aspirin/day and 200 mg cilostazol/day was started after stenting and continued for 4 weeks. There was no cardiac event during the 1 year follow-up period. Follow-up coronary angiography at 12 months after stenting revealed no in-stent restenosis. The patient was admitted 17 months later due to sudden onset of severe chest pain. Electrocardiography revealed ST segment elevation in leads V1-V4. Emergency coronary angiography disclosed obstruction of the proximal left anterior descending coronary artery with thrombus. Intracoronary aspiration thrombectomy was successful. We describe a patient with acute myocardial infarction who had late stent thrombosis 17 months after stent implantation.     

One-year clinical outcomes after sirolimus-eluting coronary stent implantation for acute myocardial infarction in the worldwide e-SELECT registry

Background: The aim was to ascertain the 1‐year clinical outcomes of 1,234 patients who underwent implantations of sirolimus‐eluting stents (SES) for acute myocardial infarction (MI) in the multinational e‐SELECT registry. Methods: Fifteen thousand and one hundred and forty‐seven patients treated with SES were entered in the e‐SELECT registry, of whom 1,234 presented within <24 hours of onset of acute MI. Results: At 1 year, the rates of major adverse cardiac events (MACE) (5.5% vs. 4.8%; P = 0.28) were similarly low in the acute and no acute MI groups. The rates of definite/probable stent thrombosis (ST) were higher in the acute MI group (2.1%vs; 0.88%, P < 0.001). ST was a strong independent predictor of death at 1 year (HR 13.4; 95% CI 5.0, 36.0; P < 0.001) and MI (HR 58.9; 95% CI 26.9, 129.1; P < 0.001). Dual antiplatelet therapy (DAPT) compliance at 6 months was 96.0% in the acute MI versus 94.5% in the no acute MI group (P = 0.03). Conclusion: In selected patients presenting within <24 hours of acute MI onset and highly compliant with DAPT, SES implantation was associated with similar rates of MACE, though higher rates of ST, as compared to no acute MI patients. Condensed abstract In the e‐SELECT registry which included 15,147 patients treated with sirolimus‐eluting stent (SES), we ascertained the 1‐year clinical outcomes of 1,234 patients who presented within <24 hours of acute MI onset. In acute MI patients SES implantation was associated with similar rates of MACE, though higher rates of ST, as compared to no acute MI patients (MACE: 5.5% vs. 4.8%; P = 0.28; ST: 2.1 vs. 0.88%, P < 0.001). (J Interven Cardiol 2012;25:253–261)     

Late angiographic stent thrombosis after sirolimus-eluting stent implantation.

BACKGROUND: Although drug-eluting stents dramatically reduce revascularization after percutaneous coronary intervention (PCI), it is still unclear whether they increase the risk of stent thrombosis. Late stent thrombosis (>30 days) was a very rare complication after bare metal stent implantation. Four cases of confirmed late angiographic stent thrombosis (LAST) after sirolimus-eluting stent (SES) implantation are presented and the incidence, promoting factors and outcomes of such cases in Japan, where clopidogrel has not been approved, are described. METHODS AND RESULTS: Between September 2004 and March 2006, 725 patients underwent PCI with SES implantation and 679 patients (94%) were clinically followed up (median 271 days). There were 4 cases (0.6%) of LAST (at 60, 180, 215, and 508 days, respectively) after elective SES implantation resulting in myocardial infarction. Three cases occurred soon after antiplatelet therapy discontinuation 3 patients died after LAST events. The incidence of LAST was 0.6%. CONCLUSIONS: LAST is a rare complication, even after SES implantation, at least in patients with appropriate antiplatelet therapy. However, as it can lead to fatal complications, it must be taken into account, especially when antiplatelet therapy is discontinued.     

Gender-specific outcomes after sirolimus-eluting stent implantation.

OBJECTIVES: We examined the impact of gender on outcomes of patients undergoing percutaneous coronary intervention using sirolimus-eluting stents (SES). BACKGROUND: Although gender-specific differences in outcome after implantation of bare-metal stents (BMS) have been described, there are no data assessing outcomes of women treated with SES. METHODS: We performed a patient-level pooled analysis from 4 randomized SES versus BMS trials (RAVEL [Randomized Comparison of a Sirolimus-Eluting Stent with a Standard Stent for Coronary Revascularization], SIRIUS [SIRolImUS-coated Bx Velocity balloon expandable stent in the treatment of patients with de novo coronary artery lesions], E-SIRIUS [Sirolimus-eluting stents for treatment of patients with long atherosclerotic lesions in small coronary arteries], and C-SIRIUS [Canadian study of the sirolimus-eluting stent in the treatment of patients with long de novo lesions in small native coronary arteries]) and analyzed outcomes as a function of gender. RESULTS: Of 1,748 patients, 1,251 were men and 497 were women. A total of 878 patients were randomized to SES (629 men and 249 women), and 870 patients were randomized to BMS (622 men and 248 women). Compared with men, women were older and more frequently had diabetes mellitus, hypertension, and congestive heart failure. Although overall clinical outcomes were similar in both genders, treatment with SES was associated with significant (p < 0.0001) reductions in rates of in-segment binary restenosis both in women (6.3% vs. 43.8%) and in men (6.4% vs. 35.6%), resulting in a significant reduction in 1-year major adverse cardiac events, driven by a lower incidence of target lesion revascularization/target vessel revascularization in both genders. By multivariable analysis, female gender was not an independent predictor of in-segment binary restenosis or clinical outcomes regardless of stent type. CONCLUSIONS: In this analysis, despite less favorable baseline clinical and angiographic features in women compared with men, the angiographic and clinical benefits of SES were independent of gender.