Jimba Takahiro, Hashikata Takehiro, Matsushita Masashiro, Yamasaki Masao
Department of Cardiovascular Medicine, NTT Medical Center Tokyo, Higashigotanda 5-9-22, Shinagawa-ku, Tokyo 141-0022, Japan.
Eur Heart J Case Rep. 2020 Feb 4;4(1):1-5. doi: 10.1093/ehjcr/ytaa001. eCollection 2020 Feb.
Hypersensitivity reaction is a classic cause of in-stent restenosis (ISR) in coronary stents, typically reported in bare-metal stents and first-generation drug-eluting stents. Biodegradable polymer sirolimus-eluting stent (BP-SES) was developed with the concept of biocompatibility, and there has been no report of ISR of BP-SES with hypersensitivity reaction.
An 81-year-old woman presented with ST-elevation acute inferior myocardial infarction. Primary percutaneous coronary intervention was performed for the culprit lesion in the left circumflex artery with a permanent polymer everolimus-eluting stent (PP-EES), followed by BP-SES implantation in the left anterior descending artery. Eight months later, coronary angiography showed total occlusion of the PP-EES and diffuse ISR in the BP-SES, treated with a paclitaxel-eluting balloon. Fluorodeoxyglucose with positron emission tomography showed increased uptake around the BP-SES, and cardiac magnetic resonance imaging revealed a late gadolinium-enhanced area around both stents. Four months later, she developed re-ISR in the BP-SES, and optical coherence tomography demonstrated diffuse-layered neointimal hyperplasia with microvascularization and peri-strut low-intensity area. She was successfully treated with coronary artery bypass grafting.
Our case demonstrated repetitive short-term ISR of the BP-SES. Observation by both intravascular and non-invasive imaging modalities suggested the presence of hypersensitivity reaction localized in the stent. Hypersensitivity to the metal may be a possible mechanism because both stents are composed of L605 cobalt-chromium alloy. This is the first report of ISR of a BP-SES with hypersensitivity reaction. Non-invasive imaging can be useful to assess this critical condition.
超敏反应是冠状动脉支架内再狭窄（ISR）的经典原因，在裸金属支架和第一代药物洗脱支架中较为常见。可生物降解聚合物西罗莫司洗脱支架（BP-SES）是基于生物相容性概念研发的，目前尚无BP-SES发生伴有超敏反应的ISR的报道。
一名81岁女性因ST段抬高型急性下壁心肌梗死就诊。对左旋支罪犯病变行急诊经皮冠状动脉介入治疗，植入永久聚合物依维莫司洗脱支架（PP-EES），随后在左前降支植入BP-SES。8个月后，冠状动脉造影显示PP-EES完全闭塞，BP-SES出现弥漫性ISR，遂采用紫杉醇洗脱球囊治疗。正电子发射断层扫描氟脱氧葡萄糖显示BP-SES周围摄取增加，心脏磁共振成像显示两个支架周围均有延迟钆增强区域。4个月后，她的BP-SES再次出现ISR，光学相干断层扫描显示弥漫性分层内膜增生伴微血管化和支架周围低强度区域。她最终成功接受了冠状动脉旁路移植术治疗。
我们的病例显示了BP-SES反复出现的短期ISR。血管内和非侵入性成像方式的观察均提示支架部位存在超敏反应。对金属的超敏反应可能是一种潜在机制，因为两种支架均由L605钴铬合金制成。这是首例关于BP-SES发生伴有超敏反应的ISR的报道。非侵入性成像有助于评估这一危急情况。
