Summary
A 79-year-old male who had a history of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) received coronary angiography (CAG), because of angina pectoris. CAG showed in-stent restenosis of the paclitaxel-eluting stent (PES). Since the devices could not pass the lesion, we performed rotational atherectomy. Although we could not identify the calcified lesion by the optical frequency domain imaging (OFDI) findings because of strong attenuation, the intravascular ultrasound (IVUS) image showed the superficial calcification. On the other hand, strong attenuation in OFDI suggested the presence of foamy macrophage, which was essential for the diagnosis of neoatherosclerosis. We could obtain a favorable result by deploying another drug-eluting stent. While an earlier report showed the calcified neoatherosclerosis following bare-metal stent implantation, we clearly showed the calcified neoatherosclerosis following PES implantation.
Highlights
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We experienced a case of calcified neoatherosclerosis following paclitaxel eluting stent (PES) implantation that required rotational atherectomy.
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Although we could not identify the calcified lesion by the optical frequency domain imaging (OFDI) findings because of strong attenuation, the intravascular ultrasound (IVUS) image showed the superficial calcification. On the other hand, strong attenuation in OFDI suggested the presence of foamy macrophage, which was essential for the diagnosis of neoatherosclerosis.
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The diagnosis of calcified neoatherosclerosis required two imaging modality: intravascular ultrasound (IVUS) and optical frequency domain imaging (OFDI), which worked in a mutually complementary manner.
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Introduction
Neoatherosclerosis have been reported after stent implantation , and causes in-stent plaque raptures, which results in late or very late stent thrombosis . Neoatherosclerosis occurred more frequently in drug eluting stent (DES) than bare-metal stent (BMS), especially in first generation DES . Calcified neoatherosclerosis that required rotational atherectomy was reported only after BMS implantation , whereas such calcified neoatherosclerosis following DES implantation has not been reported yet. We experienced a case of calcified neoatherosclerosis following paclitaxel eluting stent (PES) implantation that required rotational atherectomy. The diagnosis of calcified neoatherosclerosis required two imaging modality: intravascular ultrasound (IVUS) and optical frequency domain imaging (OFDI), which worked in a mutually complementary manner.
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Case report
A 79-year-old male with a history of coronary artery bypass grafting was referred to our medical center for stable angina. He had a coronary risk factor of hypertension, dyslipidemia and diabetes mellitus, which were appropriately controlled. His systolic blood pressure was 120 mmHg, his LDL cholesterol level was 78 mg/dl, and his hemoglobin A1c level was 7.0%. His coronary artery bypass grafting was left internal thoracic artery (LITA) to left anterior descending artery (LAD), saphenous vein graft (SVG) to diagonal branch and SVG to posterior lateral branch (PL). He also received percutaneous coronary intervention (PCI) to obtuse marginal branch (OM) 7 years ago. In PCI to OM, two paclitaxel-eluting stents (3.0 × 16 mm and 2.5 × 16 mm) were implanted following 2.5 mm semi-compliant balloon predilatation. After stent implantation, post-dilatation was added using a 3.5 mm non-compliant balloon. Although the symptom was improved, he had a recurrence of effort angina 1 month before. Although coronary angiography (CAG) revealed patency of bypass grafts, there was in-stent restenosis of paclitaxel eluting stents ( Fig. 1 A ). We planned to perform PCI to the in-stent restenosis lesion. Although the conventional guidewire passed the lesion, either 2.0 mm semi-compliant balloon or Tornus microcatheter (Asahi Intec, Nagoya, Japan) could not pass the lesion. Therefore, we performed rotational atherectomy using a 1.25 mm burr ( Fig. 1 B). After rotational atherectomy, we added balloon dilatation using a 2.0 mm semi-compliant balloon (12 atm) before intravascular imaging studies to facilitate insertion of imaging devices. To understand the lesion morphology, we performed optical frequency domain imaging (OFDI) (Terumo, Tokyo, Japan) as well as intravascular ultrasound (IVUS) imaging (Intrafocus WR, Terumo, Tokyo, Japan). OFDI showed circumferential high intensity with strong attenuation, suggesting the presence of foamy macrophage ( Fig. 1 D) . However, the presence of calcification was not clear, because of strong attenuation. On the other hand, IVUS demonstrated circumferential superficial calcification, which has cracks due to rotational atherectomy, in neointima ( Fig. 1 E). Then, we performed predilatation using a 2.5 mm non-complaint balloon (20 atm). We deployed a 2.5 × 32 mm biodegradable polymer everolimus-eluting stent over the previous stents. After post dilatation using a 3.5 mm non-compliant balloon at stent proximal site (20 atm), we could obtain a favorable result ( Fig. 1 F). The patient had been asymptomatic after the procedure. Ten months after PCI, coronary CT showed patency of the deployed stent without in-stent restenosis.
