A patient presenting with ‘edge’ in-stent restenosis 12 years after the implantation of a bare-metal stent in the mid-left anterior descending coronary artery is described. Optical coherence tomography disclosed the presence of ruptured neoatherosclerosis at the stent edge. The value of this imaging technique to unravel this unique underlying anatomic substrate is discussed. The therapy of choice for patients presenting with edge in-stent restenosis (ISR) is reviewed.
Treatment of patients presenting with in-stent restenosis (ISR) remains a challenge [1]. Neoatherosclerosis may constitute the underlying substrate of ISR [2]. We present a patient who developed very late ‘edge ISR’ caused by neoatherosclerosis.
A 63-year-old man presented with effort angina. Twelve years before, he received a bare-metal stent (BMS) in the left anterior descending coronary artery. Ten years later, repeated angiography showed an excellent stent result. Currently, coronary angiography showed a tight lesion at the distal edge of the stent (Fig. 1a). Optical coherence tomography (OCT) revealed mild, uniform, neointimal tissue proliferation along the stent. However, its distal segment showed neoatherosclerosis which, near the stent edge, progressed into a ruptured occlusive fibroatheroma with thrombus (Fig. 1b–d). Immediately distal to the stent edge, a large lipid plaque was also recognized (Fig. 1e). A drug-eluting stent (DES) was successfully implanted. Repeated OCT confirmed excellent stent expansion and apposition, but unravelled multiple areas with plaque prolapse and residual thrombus (Fig. 2).
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Neoatherosclerosis occurs less frequently and later in patients receiving BMS as compared with those treated with DES [1, 2]. Complicated neoatherosclerosis (rupture of a thin-cap fibroatheroma) may explain unstable clinical presentations in patients with ISR and in those with very-late stent thrombosis [2]. Due to its spatial resolution (15 μm), OCT represents the technique of choice for the diagnosis of neoatherosclerosis [3]. Edge-ISR occurs more frequently in patients with DES-ISR than in those with BMS-ISR [4] and repeat stenting has been advocated in this setting [5]. However, to the best of our knowledge, complicated neoatherosclerosis causing edge-ISR has not been previously reported.
Funding
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Conflict of interest
None declared.
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