Author + information
- Received June 29, 2013
- Accepted July 3, 2013
- Published online April 1, 2014.
- Kenichi Fujii, MD∗,
- Hiroyuki Hao, MD†∗ (, )
- Takahiro Imanaka, MD∗,
- Taro Kawano, MD‡,
- Tadateru Takayama, MD‡,
- Atsushi Hirayama, MD‡,
- Tsutomu Yamada, PhD§,
- Hatsue Ishibashi-Ueda, MD‖,
- Seiichi Hirota, MD† and
- Tohru Masuyama, MD∗
- ∗Cardiovascular Division, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
- †Department of Surgical Pathology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
- ‡Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
- §Department of Pathology, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
- ‖Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- ↵∗Reprint requests and correspondence:
Dr. Hiroyuki Hao, Department of Surgical Pathology, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
A 57-year-old man died of sepsis, and an autopsy was performed. Previously, he had undergone percutaneous coronary intervention of the middle left anterior descending coronary artery, with 2 sirolimus-eluting stents implanted 61 months before death. Post-mortem ex-vivo optical coherence tomography (OCT) (LightLab imaging, Westford, Massachusetts), coronary angioscopy (CAS) (FiberTech, Tokyo, Japan) imaging, and pathological examination were performed in the stented segments. OCT images showed in-stent eccentric intimal growth of moderate intimal hyperplasia with rapid attenuation of the signals with diffuse border, such as a thin-cap fibroatheroma (TCFA) in native coronary arteries (Fig. 1A). Corresponding CAS images revealed that stent struts were covered by intensive yellow neointima (Fig. 1B). Corresponding histopathologic images demonstrated a large, lipid-rich necrotic core covered with a thin fibrous cap infiltrated by lipid-laden macrophages with few smooth muscle cells (Figs. 1C and 1D).
Based on recent pathological study, rupture of a TCFA-like lesion within the neointima has been reported in the long term after stent implantation and has been proposed to be responsible for very late stent thrombosis (1). To the best of our knowledge, this is the first case of ex-vivo interrogation of in-stent TCFA containing neointima after drug-eluting stent implantation with OCT and CAS by autopsy specimen. On OCT images, the lipid-rich necrotic core appears as a low-signal-intensity mass because of the strong optical absorption and scattering of lipids at light wavelengths around 1,000 nm (2). Therefore, stent struts cannot be visualized by OCT if there is a lipid-rich necrotic core within the neointima. On the other hand, stent struts behind organized fibrin thrombus can be visualized because OCT signals are not attenuated by this material (3). Therefore, it is important to identify the in-stent TCFA-like neointima whether stent struts behind a low-signal-intensity area are “visible” or “invisible.”
The authors thank Mrs. Mayumi Oka and Mr. Gen Satoh for their technical assistance.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 29, 2013.
- Accepted July 3, 2013.
- American College of Cardiology Foundation
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