|Year : 2022 | Volume
| Issue : 2 | Page : 76-78
Difficulties with optical coherence tomography in assessment of an in-stent restenosis lesion
R S. Venkata Subrahmanya Sarma, Gopalakrishna Koduru, Purnachandra Rao Koduru, Somasekahr Ghanta, Sarada Srinivas Chowdary Parvathaneni, Raghuram Palaparti, Dasarath Boppana, V Swarajyam, Y Srinivas, Y Sasidhar, M Prasad
Department of Cardiology, Aayush Hospitals, Vijayawada, Andhra Pradesh, India
|Date of Submission||23-May-2021|
|Date of Decision||09-Jun-2021|
|Date of Acceptance||28-Jun-2021|
|Date of Web Publication||21-May-2022|
Dr. R S. Venkata Subrahmanya Sarma
Department of Cardiology, Aayush Hospitals, Vijayawada, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
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|| |
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|| |
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) 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 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|| |
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.,,
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).,
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. 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., 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.
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
Conflicts of interest
There are no conflicts of interest.
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