Author + information
- Received September 14, 2015
- Accepted September 24, 2015
- Published online January 25, 2016.
- ∗Zentrum für Kardiologie, Kardiologie I, University Medical Center Mainz and Deutsches Zentrum für Herz und Kreislauf Forschung, Standort Rhein-Main
- †Robert Bosch Krankenhaus, Stuttgart, Germany
- ↵∗Reprint requests and correspondence:
Dr. Tommaso Gori, Zentrum für Kardiologie, Kardiologie I, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
A 38-year-old man with a history of smoking and hyperlipidemia was admitted for sudden-onset chest pain. The pre-admission electrocardiogram (ECG) showed ST-segment elevation in leads V4 through V6. After administration of 5000 IU heparin and 250 mg aspirin intravenously, the patient underwent urgent coronary angiography that showed an occluded intermediate branch and a stenosis of the circumflex coronary artery (Figure 1A). Both lesions were treated with Absorb bioresorbable scaffolds (respectively 3.0 × 18-mm and 3.0 × 28-mm at 12 and 14 atm; Abbott Vascular, Santa Clara, California) with a final Thrombolysis In Myocardial Infarction flow grade of III. Maximal creatine kinase was 2,950 U/l, and troponin I reached 55.2 ng/ml. The patient was discharged on day 3 and remained asymptomatic during early follow-up.
One month later, during a post-discharge exercise test, ECG showed a 5-mm ST-segment elevation in leads V4 through V6 (Figure 1C). A coronary angiogram was negative (Figure 1D), and a diagnosis of vasospasm was made. Sublingual nitrates were prescribed. Another 2 weeks later, the patient underwent 24-h electrocardiographic recording that also showed marked ST-segment elevations in the anterior leads (Figure 2A). Because the patient remained asymptomatic, no repeat angiography was performed.
Twelve months later, the patient underwent scheduled control coronary angiography (Figures 2B to 2E, Online Video 1). On optical coherence tomography (Figure 2B) (Ilumien Optis, St. Jude Medical, St. Paul, Minnesota), the scaffold was well apposed, with a <200-mm neointimal layer. There was no evidence of atherosclerotic plaque either in-segment or at the edges. Selective intracoronary infusion of acetylcholine caused a complete vasospastic occlusion of the scaffolded segment (Figure 2D), which was fully resolved by intracoronary nitroglycerin (Figure 2D, Online Video 2).
Severe vasospasm is a known complication after stenting, in particular with drug-eluting stents (1). The loss of radial force caused by the reabsorption of the scaffold struts unmasked the abnormal vasoconstrictor responses to acetylcholine in this case. Alternatively, acetylcholine caused protrusion of the vessel wall through the stent struts. To our knowledge, there is only 1 previous case of vasospasm causing complete vessel occlusion in a segment treated with a drug-eluting stent (2). Therapy with sublingual organic nitrates was prescribed; 12 months after the index event, the patient reports general well-being with sporadic episodes of chest pain at rest and during exercise.
For supplemental videos, please see the online version of this article.
Drs. Gori and Münzel have received speaker honoraria from Abbott Vascular and support from the Mainz Center for Translational Vascular Biology. Dr. Sechtem has reported that he has no relationships relevant to the contents of this paper to disclose.
- Received September 14, 2015.
- Accepted September 24, 2015.
- American College of Cardiology Foundation
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