Angioscopy and OCT in Repeated In-Stent Restenosis in Saphenous Vein Graft
Tetsuya Fusazaki, MD*,
Tomonori Itoh, MD,
Tatsuhiko Koeda, MD,
Takumi Kimura, MD,
Yoshinobu Ogino, MD,
Hiroki Matsui, MD,
Shoma Sugawara, MD,
Motoyuki Nakamura, MD
The morphological characteristics of in-stent restenosis (ISR) that occur in multiple layers of stents (stent in stent) are not well described. We used multimodality imaging in a 69-year-old man in whom repeated episodes of restenosis developed in a 9-year-old saphenous vein graft (SVG) to the left circumflex artery. He was initially treated with a sirolimus-eluting stent (SES) after the first stenosis. Two years later, ISR developed that was treated with another SES. Once again, re-ISR developed 19 months later inside the SES that was implanted for ISR of the initial SES. Multimodality imaging (intravascular ultrasound [IVUS], coronary angioscopy, and optical coherence tomography [OCT]) were used (Fig. 1). IVUS showed the culprit lesion, which was an ISR lesion, to be echolucent tissue. Coronary angioscopy showed it to be sharply demarcated white tissue. OCT findings of the lesion showed that although the surface of the culprit lesion (which appeared as a white surface by angioscopy) was a signal-rich structure, underneath it contained a low signal and some microchannels in the deeper layer tissue. Percutaneous coronary intervention was performed with a distal protection device, and the pathological examination of the aspirate demonstrated fibrin clots (Fig. 2). Kume et al. (1) reported earlier that signal-rich structures without backscattering visualized by OCT are fibrin clots. The low-signal images in the deep tissue layer contained microchannels suggestive of organized thrombi. These results indicate that the white neointima-like coverage visualized by angioscopy after SES implantation could be a fibrin clot covering chronically formed thrombi, and that multimodality imaging could help in understanding the pathogenesis of ISR patterns after drug-eluting stent implantation.
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Figure 1 Comparison of IVUS, Coronary Angioscopy, and OCT Images of the Culprit Lesion
Although intravenous ultrasonography (IVUS) images of proximal sides were uncovered (A) or covered (B) by neointimal hyperplasia (arrowheads), culprit lesions demonstrated an echolucent area (*) (C, D). Angioscopic findings show uncovered stent struts with red thrombus (black arrowheads), partially covered by neointima on the proximal side of the sirolimus-eluting stents (E). Optical coherence tomography (OCT) image shows malapposed stent strut of sirolimus-eluting stents with or without neointima of stent strut and partially well apposed with neointima (I). Angioscopy shows flesh-colored neointima-like coverage proximal to the culprit lesion (F), and well apposed with high-intensity neointima by OCT (J). Angioscopic findings of culprit lesions show sharply demarcated (black arrows) white coverage tissue (G, H). OCT images of the same portions show a high-intensity layer. However, deep tissue is low intensity and contains some microchannels (white arrows) (K, L). See Online Videos 1, 2, 3, and 4.
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Appendix
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For supplementary videos and their legends, please see the online version of this article.
* Division of Cardiology, Department of Internal Medicine and Memorial Heart Center, Iwate Medical University School of Medicine, 1-2-1, Chuo-dori, Morioka City, 020-8505, Iwate, Japan (Email: t_fusazaki{at}imu.ncvc.go.jp).
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REFERENCES
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- Kume T, Okura H, Kawamoto T, et al. Fibrin clot visualized by optical coherence tomography Circulation 2008;118:426-442.[Free Full Text]
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