Optical coherence tomographic insights of very late stent thrombosis of a second-generation drug-eluting stent: a case report

Figure 1. Electrocardiogram at presentation showing T-wave inversion in leads LII, LIII, and aVF.

Figure 2. A selective coronary angiogram (A) In 2012 revealed diffuse lesion in the right coronary artery, causing critical stenosis. (B) A metal jacket right coronary artery after implantation of a 3.5 mm × 30 mm stent in the proximal-right coronary artery, 3.0 mm × 30 mm stent in mid-right coronary artery, and a 2.75 mm × 30 mm stent in the distal-right coronary artery (zotarolimus-eluting Endeavor Spirit stents, Medtronic Vascular, CA, USA) with adequate overlap (arrow indicate proximal overlap) at stent edges are shown. (C) In the year 2021, reveals diffuse in-stent restenosis extending from proximal to middle stented segment with slight haziness at the proximal stent overlap (arrow), causing 90% stenosis. Points marked A to G correspond to cross-sectional optical coherence tomographic images in Figure 3. The point marked D corresponds to the arrow in B, indicating a proximal stent overlap segment.

Figure 3. Optical coherence tomography imaging of right coronary artery. Middle Panel: Longitudinal image reveals well-apposed stent struts throughout the length with intimal hyperplasia and/or diffuse neo-atherosclerosis extending from the distal to the proximal stented segment, causing a variable degree of luminal area reduction with maximal luminal area stenosis of 88% at the point marked C. A to H correspond to cross-sectional optical coherence tomography images in the upper and lower panel of this figure as well as to the angiographic image of Figure 2C. Upper and Lower Panel: Cross-sectional optical coherence tomography images show (A) distal normal reference segment with the vessel diameter of 3.2 mm measured from external elastic lamina to external elastic lamina. (B) Predominantly a fibrotic neo-intimal hyperplasia () within the distal right coronary artery stent. (C) Heterogeneous fibro-lipidic () neo-atheroma (covering > 180° arc) causing in-stent restenosis with 88% luminal area stenosis. (D) Proximal stent overlap segment (arrowheads) with plaque rupture () in a predominantly lipid-rich neo-atheroma and an extensive white thrombus (). (E) Fibro-lipidic plaque () with erosion…

Figure 4. Optical coherence tomographic images of right coronary artery illustrating no under-expansion (A–E) and dissection (F). (A) Distal normal reference diameter as measured from external elastic lamina to external elastic lamina is shown. (B–E) Neo-atheroma segment showing mean stent diameter and stent expansion of the distal right coronary artery stent (B), distal-mid stent overlap segment (C), and mid-proximal stent overlap segment (D, E). Overlap segment is evident by double layer of stent struts (C–E). (F) Dissection after balloon dilatation near the proximal edge of the stent covering an angle of 45° and extending proximally towards the guide catheter tip (star) for a length of 4 mm (corresponding longitudinal image), which required stenting are shown. White arrows indicate corresponding points in the longitudinal image.

Figure 5. Post-percutaneous coronary intervention optical coherence tomographic and angiographic images of right coronary artery. Longitudinal image of distal (A) and proximal (B) part of right coronary artery with corresponding cross-sectional images indicated by arrows. (C) A minimal lumen area of 5.60 mm2 is shown. (D) Minimal stent area of 6.54 mm2 and stent expansion of 98% in the newly stented segment. (E) Well-expanded and well-apposed stent in a part of proximal right coronary artery are shown. (F) Stent malapposition in the upper part, which was later dilated with a 4.5 mm balloon guided by OCT. (G) Final post-PCI angiographic image with thrombolysis in myocardial infarction 3 flow and no residual stenosis.