Abstract
Hypersensitivity reaction towards the stent polymer resulting in formation of evaginations has been detected predominantly after treatment by the first generation drug eluting stents. This case shows that despite the use of more biocompatible polymers in second generation drug eluting stents there will still be patients developing adverse vessel wall reactions consistent with a hypersensitivity reaction towards the implanted stent.
A 71-year-old man was treated for a chronic occluded left anterior descending artery (LAD) at the LAD/D1 bifurcation. The patient was randomized in the Nordic Bifurcation study IV to treatment by two-stent technique for the Medina class 0.1.1 lesion. The occlusion was wired in the true lumen and predilated. The mini crush technique was performed using two 18 mm Xience Prime stents (Abbott Vascular, CA, USA) achieving a satisfactory result by angiography ( Fig. 1 : A) and by optical coherence tomography (OCT) ( Fig. 1 : D1, E1). Planned 8-month follow-up revealed formation of evaginations in a 5.6 mm long segment in the distal main vessel ( Fig. 1 : D2, D3 and E2, E3). Matched baseline and follow-up OCT analysis showed unchanged stent dimensions (frame 1: diameter 3.20 mm to 3.25 mm and frame 2: 3.16 mm to 3.23 mm) and increased extra-stent lumen illustrated by red areas in Fig. 1 (D3, E3, QCU-CMS, Leiden University Medical Center, Netherlands). Reconstructed 3D OCT movie loops revealed a vessel wall with irregular surface, mal apposed stent struts and evaginations ( Movie 1 and 2 , QAngioOCT Research Edition 1.0, Medis Specials bv, Leiden, Netherlands). The patient was treated indefinitely with clopidogrel and aspirin due to prior ischemic stroke. The presence of peri-stent evaginations was also decided to indicate indefinite dual antiplatelet therapy. Follow-up was without coronary events after 10 months.
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