Very Late Thrombosis of an Undersized Bare-Metal Stent

Abstract

A 52-year-old gentleman was admitted with anterior non ST elevation myocardial infarction. He had a history of stenting of the left anterior descending (LAD) – first diagonal (D₁) bifurcation with two bare-metal stents (BMS) according to the provisional T-technique ten years earlier. He was also submitted to a simple balloon angioplasty for focal LAD in-stent restenosis 14 months ago.  The urgent coronary angiography this time showed a very late stent thrombosis  of the LAD BMS fortunately with preserved distal flow. He was initially treated successfully with aspiration thrombectomy combined to few days of aspirin, prasugrel and enoxaparin to enable complete thrombus dissolution.  Five days later the LAD stent was examined with optical coherence tomography (OCT) which revealed severe malapposition proximally to the D₁ due to initial BMS undersizing. The stent was expanded and a kissing-balloon inflation was performed at the LAD – D₁ bifurcation with appropriately sized balloons. Finally, after verifying the correct stent expansion and apposition by OCT, a drug-eluting balloon inflation was performed in-stent in order to minimize the risk of restenosis. Subsequent clinical course was uneventful. Details and images concerning these procedures are presented and discussed herein.