Takeda Morihiko, Shiba Nobuyuki
Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi, Japan.
J Cardiol Cases. 2024 Feb 2;29(5):209-213. doi: 10.1016/j.jccase.2024.01.004. eCollection 2024 May.
In 2020, a 48-year-old male patient was admitted to our hospital due to unstable angina. In 2005, three first-generation sirolimus-eluting stents (1st-SESs) had been deployed to his right coronary artery (RCA). Over the past 10 years or so, the patient has been treated with single antiplatelet therapy using aspirin. Coronary angiography (CAG) revealed severe stenosis in the left circumflex artery (LCx) and total occlusion at the proximal portion of the stented RCA. Furthermore, fluoroscopy showed multiple 1st-SES fractures. After ad hoc percutaneous coronary intervention of the LCx, dual antiplatelet therapy (DAPT) was resumed by adding the P2Y12 inhibitor clopidogrel to aspirin. Two months later, CAG revealed complete recanalization and multiple peri-stent coronary artery aneurysms (CAAs) in the RCA. Intravascular ultrasound revealed late-acquired stent malapposition (LSM) and formation of true aneurysms. Coronary angioscopy showed the uncovered struts of the 1st-SES and mural red thrombus. DAPT was continued thereafter, and 8 months later, follow-up CAG showed no significant RCA restenosis. To date, the patient remains free from cardiovascular events. This report documents a rare case of thrombotic occlusion of a 1st-SES with LSM, CAA, and stent fractures followed by non-invasive recanalization after clopidogrel treatment 15 years after 1st-SES implantation.
Stent thrombosis due to stent fracture and coronary aneurysm can occur even years after first-generation sirolimus-eluting stent (1st-SES) implantation. Risk assessment using coronary imaging should be made and long-term dual antiplatelet therapy (DAPT) should be recommended in patients with a high risk of stent thrombosis after 1st-SES implantation. In cases of stent thrombosis of the 1st-SES, resuming DAPT, including P2Y12 receptor inhibitors, may be a useful non-invasive treatment option.
2020年，一名48岁男性患者因不稳定型心绞痛入住我院。2005年，其右冠状动脉（RCA）植入了3枚第一代西罗莫司洗脱支架（1st-SES）。在过去10年左右的时间里，该患者一直使用阿司匹林进行单一抗血小板治疗。冠状动脉造影（CAG）显示左旋支动脉（LCx）严重狭窄，支架植入的RCA近端完全闭塞。此外，透视显示多个1st-SES骨折。对LCx进行临时经皮冠状动脉介入治疗后，通过在阿司匹林基础上加用P2Y12抑制剂氯吡格雷恢复双联抗血小板治疗（DAPT）。两个月后，CAG显示RCA完全再通，且有多个支架周围冠状动脉瘤（CAA）。血管内超声显示晚期获得性支架贴壁不良（LSM）和真性动脉瘤形成。冠状动脉血管镜检查显示1st-SES的裸金属支架丝和壁内红色血栓。此后继续进行DAPT，8个月后，随访CAG显示RCA无明显再狭窄。迄今为止，该患者未发生心血管事件。本报告记录了一例罕见病例，即第一代西罗莫司洗脱支架植入15年后，1st-SES发生血栓闭塞伴LSM、CAA和支架骨折，氯吡格雷治疗后实现无创再通。
第一代西罗莫司洗脱支架（1st-SES）植入后数年，仍可能发生因支架骨折和冠状动脉瘤导致的支架血栓形成。应使用冠状动脉成像进行风险评估，并对1st-SES植入后支架血栓形成风险高的患者推荐长期双联抗血小板治疗（DAPT）。对于1st-SES支架血栓形成的病例，恢复包括P2Y12受体抑制剂在内的DAPT可能是一种有用的无创治疗选择。
