Abstract
Nickel is the most frequent allergen in patients with allergic contact dermatitis and nickel allergy has been associated with recurrent in-stent restenosis. However, it is often misdiagnosed because of a low suspicion threshold. It should be discarded in patients with recurrent in-stent restenosis, especially if their medical history reveals prior contact dermatitis. It is also noteworthy and rarely specified that even newer generation stents that use novel metal alloys also contain low amounts of nickel. To avoid the implantation of new stents containing this metal, when percutaneous coronary intervention is indicated, drug eluting balloons or bioresorbable vascular scaffolds associated with small doses of steroids could provide good alternatives of treatment. To the best of our knowledge, this is the first description of this therapeutic alternative in such an exceedingly rare clinical scenario.
Highlights
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Nickel allergy has been associated with recurrent in-stent restenosis.
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Early recognition of this etiopathogenic origin is rare and it is often misdiagnosed because of a low suspicion threshold.
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It should be discarded in patients with recurrent in-stent restenosis, especially if their medical history reveals prior contact dermatitis.
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Even newer generation stents that use novel metal alloys also contain low amounts of nickel.
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To avoid the implantation of new stents containing this metal, drug eluting balloons or bioresorbable vascular scaffolds associated with small doses of steroids could provide good alternatives of treatment.
A 64-year-old female underwent a percutaneous coronary intervention (PCI) with 2 cobalt-chromium (CoCr) everolimus-eluting stents (EES) at proximal-mid left anterior descending (LAD) and with one CoCr-EES at right coronary artery (RCA). Two years later, she presented an occlusive restenosis at mid RCA and at mid LAD with bad distal vessel. Circumflex artery (Cx) showed no significant lesions ( Fig. 1 A–C ). After Heart team evaluation, a PCI with a CoCr-sirolimus-eluting stent at distal RCA and a CoCr-zotarolimus-eluting stent (ZES) at proximal-mid RCA was performed. During LAD PCI, balloon expansion through previous stents was extremely difficult ( Fig. 1 D), so we performed in-stent rotational atherectomy with a 1.5 mm burr. Afterwards we could expand non-compliant balloons at high pressure and implant four overlapped CoCr-ZES from mid LAD to left main with good final result ( Fig. 1 E). Six months later, the patient presented new severe restenosis at both vessels ( Fig. 1 F-G). Due to the recurrent and aggressive restenosis, metal allergy was suspected. The patient revealed previous contact dermatitis and a specific test confirmed nickel allergy. After this finding, PCI with paclitaxel eluting balloons was performed with good final result. Six months later, a single photon emission cardiac tomography showed a severe anterior ischemia. A new coronary angiography (CA) showed a critical restenosis at ostial LAD, and a severe restenosis at mid-LAD with an occluded distal vessel ( Fig. 1 H–I). RCA presented a moderate restenosis at mid and distal segment. The unexpected finding was a critical ostial stenosis at Cx artery (the only vessel that had not been treated before that offered collateral circulation to RCA and LAD) ( Fig. 1 H). At this point, the heart team decided to perform coronary artery bypass grafting (CABG) with a left internal mammary artery (LIMA) to the Cx and with saphenous vein graft (SVG) to the posterolateral branch of the RCA. Two months later, the patient presented a non-ST elevation myocardial infarction complicated with cardiogenic shock. The echocardiogram showed inferior and anterior akinesia and lateral hypokinesia with severe ventricular dysfunction. An emergent CA showed an occlusive restenosis of ostial LAD and proximal RCA and a critical stenosis of ostial Cx ( Fig. 2 A ). SVG was occluded, probably because of the small distal vessel of the RCA and LIMA had a diffuse stenosis ( Fig. 2 B) that was supposed to be produced by an inflammatory response to surgical staples. Given the clinical scenario, we decided to perform an immediate PCI. Taking into account nickel allergy, we discarded a new metallic stent and implanted a 3.5 × 15 mm bioresorbable vascular scaffold (BVS) at LM-Cx with good final result ( Fig. 2 C). Prednisolone 30 mg/day was prescribed after PCI and slowly reduced to a maintenance dose of 2.5 mg/12 h after discharge. The addition of small doses of steroids has been successfully used to reduce the inflammatory response after PCI in similar cases . After 6 months, the patient remains asymptomatic. Angiographic follow-up showed neither restenosis nor thrombosis of the BVS and improvement of collateral circulation to RCA and LAD. Optical coherence tomography confirmed these findings and showed partial endotelization of scaffolds ( Fig. 2 D). Cardiac magnetic resonance also showed an improvement of left ventricle ejection fraction that was mildly reduced, with necrosis at basal segments of inferior and anterior walls.
