Fujisaki Tomohiro, Higa Tomitaka, Uechi Yoichi, Maehira Naoya
Department of Interventional Cardiology, Makiminato Chuo Hospital, Makiminato 1199, Urasoe, Okinawa 901-2131, Japan.
Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's and West, 1000 10th Avenue, New York, NY 10019, USA.
Eur Heart J Case Rep. 2020 Feb 11;4(1):1-5. doi: 10.1093/ehjcr/ytaa002. eCollection 2020 Feb.
Very late stent thrombosis (ST) is a concern in the era of drug-eluting stents (DESs), and ST is associated with peri-DES coronary artery aneurysmal lesions or coronary evaginations. An increasing number of cases of concurrent systemic allergic reaction and ST have been reported as Kounis syndrome (KS) in the literature. The number of patients with very late ST caused by KS is small, and further investigation of the potential pathophysiology is required.
We report a case of KS that manifested as systemic urticaria followed by very late ST 14 years after placement of two sirolimus-eluting stents (SESs). Three months after the event of ST, coronary evaginations at the stented segments were detected on intravascular optical coherence tomography.
Coronary evaginations are associated with local hypersensitivity, stent malapposition, uncovered strut, and flow disturbance that may predispose to ST. Systemic allergic reactions are known to promote platelet adhesion and aggregation. This case of KS suggests a pathophysiology in which the synergic effects between the coronary evaginations and a systemic allergic reaction may contribute to very late ST. For patients with Type 3 KS, performing follow-up intracoronary imaging tests may be important to confirm potential coronary evaginations, especially in patients with SESs.
在药物洗脱支架（DES）时代，极晚期支架血栓形成（ST）是一个令人担忧的问题，且ST与DES周围冠状动脉瘤样病变或冠状动脉膨出有关。文献中已报道越来越多并发全身过敏反应和ST的病例为库尼斯综合征（KS）。由KS引起的极晚期ST患者数量较少，需要对潜在的病理生理学进行进一步研究。
我们报告一例KS病例，表现为全身荨麻疹，在植入两枚西罗莫司洗脱支架（SES）14年后发生极晚期ST。ST事件发生三个月后，血管内光学相干断层扫描检测到支架段冠状动脉膨出。
冠状动脉膨出与局部超敏反应、支架贴壁不良、裸金属支架及血流紊乱有关，这些可能易导致ST。已知全身过敏反应会促进血小板黏附和聚集。该KS病例提示一种病理生理学机制，即冠状动脉膨出与全身过敏反应之间的协同作用可能导致极晚期ST。对于3型KS患者，进行冠状动脉内成像随访检查对于确认潜在的冠状动脉膨出可能很重要，尤其是对于植入SES的患者。
