Very late stent thrombosis

Very late stent thrombosis derived from thin-cap neoatheroma and fibroatheroma with plaque rupture assessed by with plaque rupture assessed by OCT

Young Joon Hong, MD

Yongcheol Kim, MD    

A 49-year-old woman presented with sudden onset chest pain, at rest, and evident of ST-segment elevation in the anterior leads of a 12-lead electrocardiogram. She received stent implantation with a 3.5 x 23mm sirolimus-eluting stent at the proximal portion of left anterior descending artery (LAD) 10 years ago. Dual antiplatelet therapy (DAPT), however, was discontinued since 3 years ago. Urgent coronary angiography demonstrated near total occlusion at the proximal portion of LAD, which was the same segment of previous stent implantation (Fig. 1A). Optical coherence tomography (OCT) demonstrated that a minimal lumen area of 2.17mm² in de-novo lesion (Fig. 1B) and minimal stent area of 5.71mm² in in-stent area (Fig. 1C), thin-cap neoatheroma (Fig. 1, D1), and neoatherosclerotic plaque rupture (Fig. 1, D2) upstream of the culprit site. Furthermore, OCT showed thin-cap fibroatheroma with plaque rupture of the de novo lesion in left main bifurcation area (Fig. 1, E1, E2, and E3). Incomplete strut apposition and uncovered struts were not detected. The OCT assessment led to another predilatation with a 3.5 x 10mm noncompliant (NC) balloon, and a 3.25 x 38mm everolimus-eluting stent implatation. Postdilatation was achieved with a 3.5 x 10mm NC balloon. Repeated OCT assessment demonstrated excellent stent expansion and good strut apposition without edge dissection.

OCT provides high-resolution (10µm) that enable detection of thin fibrous cap covering the lipid core (<65µm) and allows characterization of tissue components of atherosclerotic plaques. This case highlights the benefit that OCT offers in providing interventional strategies for very late stent thrombosis.

Fig 1. A: angiographic assessment demonstrating severe stenosis in proximal portion of implanted stent and diffuse haziness in in-stent area. B: OCT assessment demonstrating MLA of 2.17mm² with fibrous plaque. C: OCT cross-section demonstrating MSA of 5.71mm² in in-stent. D: OCT demonstrating thin-cap neoatheroma (arrowheads in D1 and D2) and plaque rupture (arrow in D2). E: OCT demonstrating thin-cap fibroatheroma (arrowheads in E1, E2, and E3) with intraluminal thrombus (arrow in E1) and ruptured plaque (arrow in E2).

References

1. Hong MK, Lee SY. In-Stent Neoatherosclerosis and Very Late Stent Thrombosis: An Endless Fight Against Atherosclerosis. JACC Cardiovasc Interv 2018;11:1351-3.
2. Joner M, Koppara T, Byrne RA, et al.; Prevention of PRESTIGE Investigators. Neoatherosclerosis in Patients With Coronary Stent Thrombosis: Findings From Optical Coherence Tomography Imaging (A Report of the PRESTIGE Consortium). JACC Cardiovasc Interv 2018;11:1340-50.