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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 76-78

Difficulties with optical coherence tomography in assessment of an in-stent restenosis lesion


Department of Cardiology, Aayush Hospitals, Vijayawada, Andhra Pradesh, India

Date of Submission23-May-2021
Date of Decision09-Jun-2021
Date of Acceptance28-Jun-2021
Date of Web Publication21-May-2022

Correspondence Address:
Dr. R S. Venkata Subrahmanya Sarma
Department of Cardiology, Aayush Hospitals, Vijayawada, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicc.jicc_31_21

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  Abstract 


In-stent restenosis (ISR) is a critical drawback of coronary stents, although initially described as benign, guidelines both support the use of intravascular imaging in the diagnosis and treatment of stent failure (Class IIa); however, our case highlights the limitation of optical coherence tomography in the assessment of the ISR (stent failure), it also highlights the association of self-limited severe acute respiratory syndrome coronavirus-2 illness and an acute coronary syndrome ISR presentation.

Keywords: Acute coronary event, coronavirus disease of 2019, coronary artery disease, right coronary artery, stable heart disease


How to cite this article:
Subrahmanya Sarma R S, Koduru G, Koduru PR, Ghanta S, Chowdary Parvathaneni SS, Palaparti R, Boppana D, Swarajyam V, Srinivas Y, Sasidhar Y, Prasad M. Difficulties with optical coherence tomography in assessment of an in-stent restenosis lesion. J Indian coll cardiol 2022;12:76-8

How to cite this URL:
Subrahmanya Sarma R S, Koduru G, Koduru PR, Ghanta S, Chowdary Parvathaneni SS, Palaparti R, Boppana D, Swarajyam V, Srinivas Y, Sasidhar Y, Prasad M. Difficulties with optical coherence tomography in assessment of an in-stent restenosis lesion. J Indian coll cardiol [serial online] 2022 [cited 2022 Jun 30];12:76-8. Available from: https://www.joicc.org/text.asp?2022/12/2/76/345623




  Introduction Top


Coronary angiography has several limitations in evaluating the cause for the stent failure. Intravascular ultrasound or optical coherence tomography (OCT) provides detailed assessment of native artery and stented segment and readily identifies the mechanism of the stent failure; however, OCT has limitations in evaluating the stent expansion in patients with ISR, with a thick layer of neoatherosclerosis and plaques beneath the signal attenuating plaques. Although several acute coronary syndrome (ACS) events have been reported in those who had severe COVID-19 illness, an association between self-limiting COVID illness and ACS has not been reported.


  Case Report Top


A 63-year-old diabetes mellitus and hypertension male presented with chest pain and giddiness for 10 days, his electrocardiogram showed sinus bradycardia, his echo was showing normal Left Ventricle function, but his Hs Trop T (54 ng/dl) is elevated. He had a history of coronary artery disease (CAD), underwent percutaneous coronary intervention (PCI) to proximal left anterior descending (LAD) in 2011, he was stable since then. Left Ventricle. He was discharged on dual antiplatelets and high statins. On further evaluation, he had a brief history of short duration fever for 2 days without any cough, breathlessness; it subsided on its own after 2 days in January 2021. During the present admission, his rapid antigen and reverse transcription–polymerase chain reaction for SARS-COV-2 were negative, but he had immunoglobulin G (IgG) antibodies positive for SARS-COV-2 (ELISA for COVID-19 antibodies IgG– 0.494, ref- <0.285). He was stabilized, underwent coronary angiogram, it showed a 99% ISR in mid-RCA [Figure 1], patent stent in proximal LAD, and minimal disease in LCX. He was advised to undergo OCT-guided PCI to RCA. As the patient agreed for angioplasty, RCA was engaged with JR 6F 3.5 guide and lesion was crossed with Sion blue wire, predilated with 2.5 mm and 3 mm NC balloons to higher atmospheres [Figure 2], this allowed the passage of OCT catheter. OCT showed extensive lipid-rich neoatherosclerosis and thrombus (Waksman Class II)[1] in two focal areas, Minimal stent area and expansion index were wrongly calibrated as 3.03 mm2 and 78% [Figure 3] and [Video 1]. As the stent could not be delivered, lesion was again dilated with 3.5 NC balloon at higher atmospheres, even then stent could not be implanted, hence a guideliner was used to implant the stent ( 3.5X 48 mm Serolimus eluting stent ), stent was post dilated serially with 3.5 NC, 4NC balloons. Final OCT showed Optimally expanded stent ( 86% ), with no edge dissections [Videos 2]. The patient was later diagnosed to have Waksman Class III[1] as the cause for DES-ISR, instead of Class II. He was kept on ticagrelor, aspirin, and high-dose statins; he completed 3-month follow-up without any events.
Figure 1: LAO view showing a tight in-stent restenosis lesion in mid right coronary artery

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Figure 2: Right coronary artery angioplasty runs, (a) Predilatation with a 2.5 nc balloon, optical coherence tomography run was done after that, the lesion was serially predilated with 3 (b), 3.5 Nc balloons (c), stent 3.5 × 48 SES implanted with the help of a 6F GuideLiner (d), Post dilation with 4.0 NC balloon (e), Final result showing a well expanded stent (f). please strike off

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Figure 3: Preoptical coherence tomography run showing two focal areas of in-stent restenosis with neoatherosclerosis (a and b), it is masking the stent struts, making evaluation of stent expansion in these areas difficult, MSA was falsely calibrated as 3.03 mm2. In all other areas stent is well expanded and all the struts are covered

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  Discussion Top


In-stent restenosis (ISR) is a critical drawback of coronary stents, although initially described as benign; this theory has been challenged by studies showing a high incidence of ACSs.[2],[3],[4]

The precise reasons why DES restenosis in some patients and in some segments within the same patient are still controversial. Biological, mechanical, and technical factors may contribute to ISR after DES implantation.

In contrast to angiography, intravascular ultrasound or OCT provides detailed assessment of native artery and stented segment and readily identifies the mechanism of the stent failure. The US and European guidelines both support the use of intravascular imaging in the diagnosis and treatment of stent failure (Class II recommendation, level of evidence - C).[5],[6]

In the present case, extensive lipid and thrombus laden neoatherosclerosis made evaluation of stent expansion difficult, it has obscured the calcium underneath, this leads to possible underexpansion of the stent and neoatherosclerosis (Waksman Class III) as the cause for the stent failure, as stent could not be delivered even after high-pressure dilation with an appropriate balloon. This suggests that extensive lipid-laden neoatheromatous plaque made evaluation of stent expansion difficult and also it obscured the calcium underneath, which is the prime cause for stent failure. Fujii et al.[7] showed that structures behind the low-signal intensity region are invisible because the OCT light signal does not exist in the low-signal intensity regions, such as those containing foam cell accumulation and the necrotic core, making the correct assessment of under expansion difficult in some cases, our case highlights the same.

SARS-COV-2 is currently causing a pandemic, with an exponential increase in cases worldwide. Severe cases show elevation in cardiac troponins and clinical evidence of myocardial injury, with some reported cases of myocarditis.[8],[9] It has been speculated that coronary plaque destabilization might occur in patients with excessive inflammatory response characterized by a cytokine storm, which may be further aggravated in a scenario of severe hypoxia, but a presentation of ISR ACS in a patient who had asymptomatic SARS-COV-2 infection has not been described in the literature previously.

The cause-and-effect relationship could not be established between SARS-COV-2 infection and ISR ACS. It is hypothesised that SARS-COV-2 causes persistent inflammatory, procoagulant milieu, which is the precursor for Acute coronary events, although it can not be established in this patient. however, the sequence of events and the presence of the COVID antibodies suggest that even those who had a self-limiting COVID 19 illness may also precipitate ACS. Although OCT helps in evaluating the cause for ISR in most of the cases, we have to be careful as extensively calcific lesions behind the low attenuated plaques in neoatherosclerosis may be not be seen clearly in OCT; hence, clinical judgment should prevail in treating these lesions. Aggressive or intensive antiplatelet therapy is needed even in those who are asymptomatic for SARS-COV-2 viral infection after undergoing angioplasty.

Acknowledgment

I would like to acknowledge the support of Aayush hospitals for providing the data.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shlofmitz E, Iantorno M, Waksman R. Restenosis of drug-eluting stents: A new classification system based on disease mechanism to guide treatment and state-of-the-art review. Circ Cardiovasc Interv 2019;12:e007023.  Back to cited text no. 1
    
2.
Chen MS, John JM, Chew DP, Lee DS, Ellis SG, Bhatt DL. Bare metal stent restenosis is not a benign clinical entity. Am Heart J 2006;151:1260-4.  Back to cited text no. 2
    
3.
Bainey KR, Norris CM, Graham MM, Ghali WA, Knudtson ML, Welsh RC, et al. Clinical in-stent restenosis with bare metal stents: Is it truly a benign phenomenon? Int J Cardiol 2008;128:378-82.  Back to cited text no. 3
    
4.
Nayak AK, Kawamura A, Nesto RW, Davis G, Jarbeau J, Pyne CT, et al. Myocardial infarction as a presentation of clinical in-stent restenosis. Circ J 2006;70:1026-9.  Back to cited text no. 4
    
5.
Neumann FJ, Sousa Uva M. “Ten Commandments” for th 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J 2019;40:87-165.  Back to cited text no. 5
    
6.
Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011;58:e44-122.  Back to cited text no. 6
    
7.
Fujii K, Kawakami R, Hirota S. Histopathological validation of optical coherence tomography findings of the coronary arteries. J Cardiol 2018;72:179-85.  Back to cited text no. 7
    
8.
Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol 2020;5:802-10.  Back to cited text no. 8
    
9.
Driggin E, Madhavan MV, Bikdeli B, Chuich T, Laracy J, Biondi-Zoccai G, et al. Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic. J Am Coll Cardiol 2020;75:2352-71.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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