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Archives of cardiovascular diseases
Volume 104, n° 1
pages 64-66 (janvier 2011)
Doi : 10.1016/j.acvd.2010.04.009
Received : 15 April 2010 ;  accepted : 29 April 2010
Drug-eluting stent fracture and intramyocardial coronary course
Fracture de stent coronaire et trajet intramyocardique
 

Franck Barbou , Patrick Schiano, Jacques Monsegu
Service de cardiologie, HIA du Val-de-Grâce, 74, boulevard du Port-Royal, 75230 Paris cedex 05, France 

Corresponding author. Fax: +33 1 40 51 42 15.

Keywords : Stent fracture, Drug-eluting stent, Intramyocardial coronary course

Mots clés : Fracture de stent, Stent actif, Trajet intramyocardique

Abbreviations : LAD, TIMI


Stent fracture has been suggested as one of the leading risk factors for thrombosis and in-stent restenosis in patients with an intracoronary drug-eluting stent. Contributing factors are stent in the right coronary artery, excessive tortuosity of the vessel, angulation or change of angulation after stent implantation, overlapping stents and conformability of the stent.

In the case reported, a 61-year-old man, with a history of dyslipidaemia and hypertension, was referred to our institution for incapacitating effort angina despite maximal medical treatment. Left ventricular function was normal. The coronary angiography revealed left dominant circulation with severe lesions of the left descending artery (LAD) and occlusion of the second obtuse marginale (Figure 1, Appendix A). The distal LAD was revascularized with a 2.5×18mm Cypher stent, and the mid and proximal LAD with 2.75×23mm and 3.0×28mm Cypher stents (short overlapping) (Figure 2A and B, Appendix A). At 1year, the patient described increasing effort angina with anterior, septal and apical myocardial perfusion deficit on dipyridamole stress perfusion cardiovascular magnetic resonance, without myocardial infarction (Figure 3). Coronary angiography showed grade 2 TIMI flow in the LAD, with very tight focal restenosis at the mid and final part of the 2.75×23mm Cypher stent and at the proximal and mid part of the 2.5×18mm Cypher stent. There was a complete stent fracture with contrast extravasation in the second stent and another fracture without contrast extravasation in the third stent (Figure 2C and D, Appendix A). The fractures appeared at the junction of the epicardial and intramyocardial courses of the LAD without compressive muscular bridge.



Figure 1


Figure 1. 

Initial severe lesions of the left descending artery.

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Figure 2


Figure 2. 

A and B. Left descending artery post-stenting result. C and D. At 1year, stent fractures with contrast extravasation and focal restenosis.

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Figure 3


Figure 3. 

Cardiovascular magnetic resonance dipyridamole stress perfusion, showing anterior, septal and apical abnormal myocardial perfusion reserve.

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This case illustrates the risk of fracture when a stent is implanted at the beginning or end of the intramyocardial coronary course. Ventricular contractions generate flexion, stretching and torsion forces, creating hinge points at the junction area. These constraints can lead to mechanical fatigue and fracture.

Conflict of interest statement

None.


Acknowledgments

We are thankful to Pr Jérôme Garot, Institut cardiovasculaire Paris Sud, Massy, France, who performed the magnetic resonance examination of the patient.


Appendix A. Supplementary data

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 Video 1 
Video 1. 

Severe lesions of the left descending artery.

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 Video 2 
Video 2. 

Post-stenting.

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 Video 3 
Video 3. 

Stent fractures.



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