Neointimal plaque erosion leading to very late stent failure.

A 70-year-old man with hypertension, hyperlipidaemia, diabetes, and estimated glomerular filtration rate 87 mL/min/1.73 m2 experienced worsening angina 14 years following primary percutaneous coronary intervention to proximal left anterior descending (pLAD) with a 3.0 mm × 23 mm Genous™ stent for an anterior ST-elevation myocardial infarction.

Myocardial perfusion imaging revealed inducible ischaemia in the left anterior descending territory. Coronary angiogram showed pLAD in-stent restenosis (ISR). Optical coherence tomography (OCT) using Optis™ Mobile and Dragonfly™ imaging catheter with Angio-Coregistration was performed using contrast-push (C-PUSH) technique, which allowed image acquisition in high-grade lesions: (i) OCT catheter was placed proximal to lesion (); (ii) as distal clearance was achieved using Omnipaque™ 350 contrast delivered by power injector, OCT catheter was advanced distal to the lesion () followed by (iii) image acquisition (total 22 mL contrast). This showed healed neointima, without evidence of plaque rupture, likely from a recent plaque erosion (). Plaque erosion is characterized by detachment or dysfunction of endothelial cells with overlying thrombus, intact fibrous cap with less macrophage infiltration, but increased smooth muscle cells and proteoglycans. On OCT, it is identified as thrombosis overlying a lesion with an intact fibrous cap but detachment of endothelium, with fibrous plaque being the major underlying plaque morphology.

Figure 1

(A) Optical coherence tomography catheter was placed proximal to the target lesion of interest. (B) Following distal blood clearance with contrast administered via power injector, the optical coherence tomography catheter was advanced distal to the lesion before initiation of automatic pullback for image acquisition. (C) Optical coherence tomography image taken at image of interest (Frame 0123) via C-PUSH Technique. (D) Pre-percutaneous coronary intervention image of Frame 0123, 13.0 mm from distal stent edge of existing 3.0 mm × 23 mm Genous™ stent; E) Post-percutaneous coronary intervention image of Frame 0123, 13.0 mm from distal stent edge of existing 3.0 mm × 23 mm Genous™ stent, with overlapping Resolute Onyx™ 3.0 × 26 mm drug-eluting stent.

In , the deep layer with high backscatter represents stable neointima with high collagen content. The superficial layer is likely a resorbing thrombus undergoing extracellular matrix replacement and proteoglycan deposition, with collagen deposition, smooth muscle proliferation, and consequent intimal hyperplasia and progression of ISR, leading to formation of a ‘layered plaque’. Such appearance suggested that an acute coronary event had occurred in the preceding weeks or months. The lesion was therefore pre-dilated using a non-compliant balloon and stented with Resolute Onyx™ 3.0 × 26 mm drug-eluting stent, with improvement in luminal area from 0.89 mm2 to 7.84 mm2 ( and E).

Supplementary material

Supplementary material is available at European Heart Journal - Case Reports online.

Consent: The authors confirm that informed consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance.

Conflict of interest: None declared.

Funding: None declared.

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