A patient with repeated catastrophic multi-vessel coronary spasm after zotarolimus-eluting stent implantation

Abstract

Drug-eluting stents (DES) have gained great popularity because of extraordinarily low rates of restenosis. Despite these superior clinical outcomes, several cases regarding the severe multi-vessel coronary spasm, although rare, after the placement of first generation DES have been reported. We report a case of severe, multi-vessel coronary spasm that occurred two occasions after placement of a zotarolimus-eluting stent, one of the second generation DES, in a 42-year-old man with unstable angina. The first incidence was relieved by intracoronary nitroglycerin alone, and second incident, which had combined fixed stenosis was treated with intracoronary nitroglycerin and everolimus-eluting stent.

Keywords: Coronary vessels; Drug-eluting stents; Spasm.

Fig. 1

Coronary angiogram at first admission. A: significant stenosis (arrow) in mid left anterior descending artery (LAD) (right anterior oblique cranial view). B: no significant stenosis in right coronary artery (left anterior oblique caudal view). C: good distal flow after drug-eluting stent implantation (2.75×18 mm Endeavor-R stent) in the mid LAD artery (right anterior oblique cranial view).

Fig. 2

Twelve-lead electrocardiogram showed atrial fibrillation and ST-segment elevation in lead aVR with ST-segment depression in multiple other leads, suggesting left main coronary artery disease.

Fig. 3

Coronary angiogram at on second admission. A: spastic near total occlusion in proximal left anterior descending (LAD), proximal left circumflex artery (arrows) with a patent previously implanted stent in mid LAD (right anterior oblique cranial view). B: mid right coronary artery showing spastic near total occlusion (left anterior oblique caudal view) (arrow). C and D: the spasm was completely relieved by intracoronary nitroglycerin injection.

Fig. 4

CAG and IVUS at last admission (i.e., third admission). A: spasmodic stenosis in proximal and distal LAD (arrows). B: mid right coronary artery showing spasmodic stenosis (arrow). C: a repeat CAG after intracoronary administration of nitroglycerin demonstrated fixed stenosis in the proximal LAD at the proximal edge of the previously implanted zotarlimus-eluting stent (arrow). D: IVUS showing a large amount of plaque (minimal lumen area: 3.7 mm², plaque burden: 55%). CAG: coronary angiography, IVUS: intravascular ultrasound, LAD: left anterior descending artery.

Fig. 5

Coronary angiogram (A) and intravascular ultrasound (B) after everolimus-eluting stent implantation (3.0×24 mm; Promus Element®, Boston Scientific, India). A: no residual stenosis with good distal flow. B: good stent apposition.