periperi--stent contrast staining induced stent contrast ... · the rca lesion was the rca lesion...

PeriPeri--Stent Contrast Staining induced Stent Contrast Staining induced AAcute cute CCoronaryoronary SSyndrome with Bare Metal Stentyndrome with Bare Metal StentCCoronary oronary SSyndrome with Bare Metal Stent yndrome with Bare Metal Stent

and Nobori stentand Nobori stent

Takeshi Ijichi Gaku Nakazawa Shigemitsu TanakaTakeshi Ijichi Gaku Nakazawa Shigemitsu Tanaka Naoki MasudaNaoki MasudaTakeshi Ijichi, Gaku Nakazawa, Shigemitsu Tanaka,Takeshi Ijichi, Gaku Nakazawa, Shigemitsu Tanaka, Naoki Masuda,Naoki Masuda,Norihiko Shinozaki, Nobuhiko Ogata, Yuji IkariNorihiko Shinozaki, Nobuhiko Ogata, Yuji Ikari

Tokai University School of MedicineTokai University School of MedicineKanagawa, JapanKanagawa, Japan

ANGIOPLASTY SUMMITANGIOPLASTY SUMMIT

TCTAP TCTAP 20122012

BackgroundBackgroundBackgroundBackground

Nowadays, PeriNowadays, Peri--stent contrast staining stent contrast staining (PSS) is known by many cardiologist in (PSS) is known by many cardiologist in drugdrug--eluting stent (DES) era.eluting stent (DES) era.

We show the case which had PSS in We show the case which had PSS in Nobori stent (NB) and bare metal stent Nobori stent (NB) and bare metal stent (BMS) at the same time.(BMS) at the same time.( MS) at the same time.( MS) at the same time.



BackgroundBackgroundBackgroundBackground

Imai et al Circulation 2011;123:2382Imai et al Circulation 2011;123:2382--23912391

Patient BackgroundPatient BackgroundPatient BackgroundPatient Background

58 ld58 ld F lF l58 years old58 years old FemaleFemale

Sh i h d f h h i b fSh i h d f h h i b fShe sometimes had a few short chest pains before She sometimes had a few short chest pains before one month. one month. ShSh k h i l b b lk h i l b b l ffShe She were taken to hospital by ambulance were taken to hospital by ambulance for for sustained chest pain. sustained chest pain. H ECGH ECG h d ST t l ti i l dh d ST t l ti i l dHer ECG Her ECG showed ST segment elevation in leads showed ST segment elevation in leads Ⅱ,Ⅲ,and aVF. Ⅱ,Ⅲ,and aVF. ShSh di d i f i ll di ldi d i f i ll di lShe She was diagnosed as inferior wall myocardial was diagnosed as inferior wall myocardial infarction and transferred to our cath lab.infarction and transferred to our cath lab.



AngiographyAngiographyAngiographyAngiography

There were There were totally totally occlusion occlusion in in proximal right coronary artery (RCA) and diffuse stenosis in mid left proximal right coronary artery (RCA) and diffuse stenosis in mid left anterior descending (LAD).anterior descending (LAD).

11stst PCI at ACSPCI at ACS11 PCI at ACSPCI at ACS

The RCA lesion was The RCA lesion was treated with a treated with a BMS. BMS. MultiLink MultiLink VISION VISION 4.0x18mm (Abott Vascular Japan)4.0x18mm (Abott Vascular Japan)

22ndnd PCI to LADPCI to LAD22 PCI to LADPCI to LAD

The patient remained asymptomatic for The patient remained asymptomatic for one month one month and she underwent a planned and she underwent a planned percutaneous percutaneous coronary intervention (PCI) for residual stenosis in mid LAD.coronary intervention (PCI) for residual stenosis in mid LAD.

22ndnd PCI to LADPCI to LAD22 PCI to LADPCI to LAD

The LAD lesion was treated with a The LAD lesion was treated with a DESDES..NoboriNobori 2.5x28mm (Terumo)2.5x28mm (Terumo)

However she had recurrent chest pain 3However she had recurrent chest pain 3However, she had recurrent chest pain 3 However, she had recurrent chest pain 3 months after 2months after 2ndnd PCI.PCI.

We performed exercise stress We performed exercise stress testing to testing to estimate her cardiac ischemia.estimate her cardiac ischemia.estimate her cardiac ischemia.estimate her cardiac ischemia.

Exercise stress testing showed ST Exercise stress testing showed ST l ti i l d Ⅲl ti i l d Ⅲ VFVFelevation in leads Ⅲelevation in leads Ⅲ,, aVF.aVF.

We diagnosed recurrent cardiac ischemia We diagnosed recurrent cardiac ischemia ggand underwent emergent coronary and underwent emergent coronary angiography (CAG)angiography (CAG)angiography (CAG).angiography (CAG).



33rdrd PCI at ACSPCI at ACS33 PCI at ACSPCI at ACS

CAG showed restenosis and PSS at the BMS in RCA. CAG showed restenosis and PSS at the BMS in RCA.


There was restenosis and PSS at the DESThere was restenosis and PSS at the DES in LAD. It was similar to the lesion of RCA.in LAD. It was similar to the lesion of RCA.


StentStent

PSSPSS

We underwent PCI for RCAWe underwent PCI for RCA. We performed intravascular ultrasonography (IVUS) at the culprit lesion, . We performed intravascular ultrasonography (IVUS) at the culprit lesion, which showed which showed stenosis in the stent and coronary aneurysm around it.stenosis in the stent and coronary aneurysm around it.


StentStent

PSSPSS

In addition to, we performed optical coherence tomography (OCT) at the lesion.In addition to, we performed optical coherence tomography (OCT) at the lesion.


We treated the lesion with a DES. Endeavor Splint 3.5x24mm (Medtronic Japan)We treated the lesion with a DES. Endeavor Splint 3.5x24mm (Medtronic Japan)


PSSPSSPSSPSS

StentStent

Then we performed for the lesion at LAD. IVUS showed the lesion produced similar findings to it at the Then we performed for the lesion at LAD. IVUS showed the lesion produced similar findings to it at the RCA.RCA.


StentStent

PSSPSS

This is OCT imaging for the PSS lesion at LAD.This is OCT imaging for the PSS lesion at LAD.


We treated the lesion with a DES. Endeavor Splint 3.5x18mmWe treated the lesion with a DES. Endeavor Splint 3.5x18mm (Medtronic Japan)(Medtronic Japan)

In order In order to differentiate the cause to differentiate the cause of PSS, of PSS, l d h ki t h t tl d h ki t h t twe planned her skin patch test.we planned her skin patch test.

10 days before skin patch test10 days before skin patch test, she had , she had y py precurrent chest pain. recurrent chest pain.

It was 4 months after 3It was 4 months after 3rdrd PCIPCIIt was 4 months after 3It was 4 months after 3rdrd PCI.PCI.

We underwent emergent CAG.We underwent emergent CAG.



CAGCAGCAG CAG

CAG showed there were restenosis and PSSCAG showed there were restenosis and PSS at the same lesion in RCA and LAD.at the same lesion in RCA and LAD.

CAGCAGCAG CAG

From these results, we finally planned her coronary artery bypass grafting (CABG).From these results, we finally planned her coronary artery bypass grafting (CABG).

Skin Patch TestSkin Patch TestSkin Patch TestSkin Patch Test

←←K2Cr2O7K2Cr2O7


←←NiSO4NiSO4


←←NiSO4NiSO4

NiSO4NiSO4

3 days later3 days later 77 days laterdays later

We checked We checked her metallic allergy before CABG. Skin patch test was positive by her metallic allergy before CABG. Skin patch test was positive by potassium potassium dichromate dichromate (K2Cr2O7) and Nickel (K2Cr2O7) and Nickel sulfate (sulfate (NiSO4). NiSO4).

DiscussionDiscussionDiscussionDiscussionNowadayNowadayss etiology of PSS is reported asetiology of PSS is reported asNowadayNowadayss etiology of PSS is reported as etiology of PSS is reported as follows,follows,

①①Tear of the coronary mediaTear of the coronary media

②②Metallic allergyMetallic allergy②②Metallic allergyMetallic allergy

③③Absorption of hematomaAbsorption of hematoma induced stent induced stent implantationimplantation

We described that PSS was occurred by We described that PSS was occurred by t lli ll i thit lli ll i thimetallic allergy in this case.metallic allergy in this case.



ConclusionConclusionConclusionConclusion

We experienced the PSS andWe experienced the PSS andWe experienced the PSS and We experienced the PSS and restenosis with BMS and Nobori restenosis with BMS and Nobori stent. stent. We diagnosed PSS by metallicWe diagnosed PSS by metallicWe diagnosed PSS by metallic We diagnosed PSS by metallic allergy in this case. allergy in this case. allergy in this case.allergy in this case.



periperi--stent contrast staining induced stent contrast ... · the rca lesion was the rca lesion...

Documents