Very Late In-stent Restenosis due to Neoatherosclerosis in the Second-generation Everolimus-eluting Stent

Implantation of metallic stents in the atherosclerotic lesions resolved the lumen stenosis or obstruction of a coronary artery and myocardial ischemia. The phenomenon of transformation of proliferating neointima into atheromatous intima is now recognized as neoatherosclerosis that can lead to stent failure including restenosis or thrombosis at the late phase after stent implantation. Although neoatherosclerosis in the second-generation drugeluting stent (DES) had been found by the proper signal patterns of optical coherence tomography, there is no certification by direct visualization using angioscopy. An 85-year-old woman with dyslipidemia and hypertension, chronic kidney disease admitted to our hospital suffered from recurrent angina pectoris of effort. She had a history of successful stent implantation for stable angina pectoris two years ago. Cobalt chromium everolimus-eluting stent was implanted into the mid left anterior descending artery. Coronary angiography showed focal restenosis in the stent segment. Coronary angioscopy identified intense yellow plaque at the same lesion. In this case, late stent failure presented as restenosis in the second-generation EES was caused by neoatherosclerosis. To the best of our knowledge, this is the first report of neoatherosclerosis in the second-generation everolimus eluting stent validated by angioscopy.