Sirolimus-eluting Stent Fracture Research Articles

Fracture of coronary artery sirolimus eluting stent with formation of four aneurysms

Coronary stent fracture is a relatively rare but potentially serious complication of coronary artery stenting, in particular with sirolimus-eluting stents. It has been recognized as one possible cause of in-stent restenosis as well as acute stent thrombosis. The formation of coronary artery aneurysm is one of the critical complications after percutaneous coronary intervention and it has been described after a stent fracture too. We report here a case of formation of four coronary artery aneurysms associated with the fracture of a sirolimus-eluting stent.

Impact of sirolimus-eluting stent fractures without early cardiac events on long-term clinical outcomes: A multislice computed tomography study

This study sought to evaluate the impact of sirolimus-eluting stent (SES) fractures on long-term clinical outcomes using multislice computed tomography (MSCT). In this study, 528 patients undergoing 6- to 18-month follow-up 64-slice MSCT after SES implantation without early clinical events were followed clinically (the median follow-up interval was 4.6 years). A CT-detected stent fracture was defined as a complete gap with Hounsfield units (HU) <300 at the site of separation. The major adverse cardiac events (MACEs), including cardiac death, stent thrombosis, and target lesion revascularisation, were compared according to the presence of stent fracture. Stent fractures were observed in 39 patients (7.4 %). MACEs were more common in patients with CT-detected stent fractures than in those without (46 % vs. 7 %, p < 0.01). Univariate Cox regression analysis indicated a significant relationship between MACE and stent fracture [hazard ratio (HR) 7.65; p < 0.01], age (HR 1.03; p = 0.04), stent length (HR 1.03; p < 0.01), diabetes mellitus (HR 1.77; p = 0.04), and chronic total occlusion (HR 2.54; p = 0.01). In the multivariate model, stent fracture (HR 5.36; p < 0.01) and age (HR 1.03; p = 0.04) remained significant predictors of MACE. An SES fracture detected by MSCT without early clinical events was associated with long-term clinical adverse events. • Long-term outcomes of sirolimus-eluting stent fracture have not been fully clarified. • MSCT could detect stent fracture with high accuracy. • Sirolimus-eluting stent fracture detected by MSCT was associated with long-term adverse events.

Letter by Vorpahl and Foerst Regarding Article, “Impact of Sirolimus-Eluting Stent Fracture on 4-Year Clinical Outcomes”

To the Editor: We read with interest the recent publication by Umeda et al, “Impact of Sirolimus-Eluting Stent Fracture on 4-Year Clinical Outcomes.”1 The authors present the important finding that stent fracture in sirolimus-eluting stents was associated with a higher major …

Long-term clinical and angiographic outcomes of patients with sirolimus-eluting stent fracture

BackgroundThere is limited data on the long-term outcomes of patients with sirolimus-eluting stent (SES) fracture. MethodsAfter performing index percutaneous coronary intervention (PCI) with SES from Dec. 2003 to Dec. 2007, the patients with stent fracture (SF) detected by angiography at follow-up or adverse events were enrolled. SF was angiographically defined as complete or partial separation of the stent and this had been contiguous after stenting. The patients were divided into two groups as SF without in-stent restenosis (ISR) (Group 1, n=55) and SF with ISR (Group 2, n=44) and the patients were clinically and angiographically followed up after the detection of SF. The major adverse cardiovascular events (MACE), including cardiac death, myocardial infarction (MI), target vessel revascularization (TVR), and stent thrombosis (ST) were determined. ResultsAt SF detection, most patients were asymptomatic (92.7% in Group 1 vs. 43.2% in Group 2, p=0.001). Acute coronary syndrome developed in 18.2% of Group 2, but it developed in only 1.8% of the patients of Group 1. Clinical follow-up was done in all patients for 675±375days from SF detection. From the detection of SF, MACEs were noted in 32.3% of the patients (10.9% in Group 1 vs. 59.1% in Group 2, p=0.001), mostly from TVR (9.1% in Group 1 vs. 54.5% in Group 2, p=0.001). ConclusionThe long-term follow-up results of SF after SES implantation show an increased risk of adverse cardiac events, and especially for the patients with ISR.

Sirolimus-Eluting Stent Fracture and Aneurysm Formation in a Young Child With a Coronary Artery Bypass Graft

Clinical experience with coronary stent implantation in children is very limited. In-stent restenosis, thrombosis, and aneurysm formation are known complications. Recently, fracture of a drug-eluting stent was reported to be a cause of in-stent restenosis, but the natural course of stent fracture and proper management options remain uncertain. This report describes the case of a 7-year-old boy with a sirolimus-eluting stent implanted to treat stenosis of a coronary artery bypass graft who showed complete stent fracture and aneurysm formation. During the 2-year follow-up period, the boy experienced complete regression of the aneurysm without in-stent restenosis.

Predictors of stent fracture in patients treated with closed-cell design stents

The aim of this study was to evaluate the predictors of coronary stent fracture in patients treated with closed-cell design stents including the sirolimus-eluting stent (SES) and its bare-metal platform, Bx velocity stent (BVS). Various mechanical factors have been considered to be the predictors of stent fracture, especially in patients treated with SES. However, it is unknown whether SES is more prone to fracture compared with BVS. We retrospectively analyzed 391 lesions treated with SES or BVS in 339 patients who underwent follow-up coronary angiography. A total of 30 stent fractures (7.7%) in 28 patients treated with 29 SES (96.7%) and one BVS (3.3%) was found. On univariate analyses, stent fracture was related to angulated lesions (>45°) during diastole, longer stent, larger number of stents per lesion (P<0.001), right coronary artery (RCA) placement (P=0.008), and SES (P=0.016). On multivariate analyses, however, angulated lesion (odds ratio: 6.73; 95% confidence interval: 2.71-16.71; P<0.001) and RCA placement (odds ratio: 2.82; 95% confidence interval: 1.03-7.72; P=0.044) served as independent predictors of stent fracture while SES (P=0.080) and total stent length (P=0.069) showed only trends that did not reach statistical significance. This study showed that fracture of SES or BVS with the same closed-cell design platform was related to angulated lesion and RCA placement, but SES itself was not an independent predictor of stent fracture.

Exaggerated inflammatory response following sirolimus-eluting stent fracture

Exaggerated inflammatory response following sirolimus-eluting stent fracture

Late asymptomatic sirolimus-eluting stent fracture in a female with systemic lupus erythematosus

We report a case of a sirolimus eluting (Cypher, Johnson-Johnson) stent fracture (SF) incidentally depicted 3 years post PCI in an asymptomatic female with systemic lupus erythematosus (SLE). The vessel was assessed with intravascular ultrasound (IVUS) and optical coherence tomography (OCT). Different imaging modalities results are presented. OCT may offer superior imaging of SF compared to fluoroscopy and IVUS and might prove useful for the detailed assessment and tailored treatment of this rare complication.

Complete Fracture of Sirolimus-Eluting Stent in a Saphenous Vein Graft to Left Anterior Descending Artery

Coronary stent fractures have been suggested as a potential new mechanism of restenosis. The mechanical properties of stents were designed not only to prevent vessel recoil, but also to resist the mechanical stress of vessel movement over millions of cardiac cycles. We present a case in which mechanical stress may have contributed to the fracture of a stent implanted in a saphenous vein graft (SVG) to the left coronary artery. The patient was admitted due to chest pain 2 years after receiving a coronary artery bypass graft. A coronary angiography revealed the culprit vessel to be the SVG to the left coronary artery. The graft was stenosed and was stented with a sirolimus-eluting stent. A 6-month follow-up coronary angiography revealed 80% in-stent restenosis with stent fracture. We re-intervened by balloon angioplasty. This is the first report of sirolimus-eluting stent fracture combined with restenosis of SVG in Korea.

Fracture of a paclitaxol-eluting stent implanted for in-stent restenosis at the site of sirolimus-eluting stent fracture

We report a patient with fracture of a paclitaxol-eluting stent implanted for focal in-stent restenosis (ISR) with sirolimus-eluting stent fracture. This case report suggests that a drug-eluting stent (DES) implanted for ISR with DES fracture may develop recurrent stent fracture.

Strut fracture: a further concern with drug-eluting stents

A potential cause of drug-eluting stent restenosis is strut fracture. To date, few cases have been reported in the available literature and a best treatment method has not been established. We describe two cases of sirolimus-eluting stent fracture combined with focal restenosis and also review those previously reported.

The use of intra-coronary optical coherence tomography for the assessment of sirolimus-eluting stent fracture

Drug-eluting stents (DES) have made a tremendous impact on the practice of percutaneous coronary intervention. Recently however, long-term DES failures have become a focal point, particularly with restenosis and thrombosis. An uncommon, yet important cause of DES failure is stent fracture. Of the two established first generation DES, the sirolimus-eluting stent (SES) has been particularly linked to cases of stent fracture, likely as a result of its closed cell design compared with other DES employing an open cell system. We present 2 cases of SES fracture confirmed using high-resolution intravascular optical coherence tomography giving unique insights into the in-vivo appearance of this complication.

Impressive sirolimus-eluting stent fracture immediately after stent implantation: A case report

In-stent restenosis (ISR) is dramatically reduced in the drug eluting stent (DES) era in comparison to the bare metal stent era [1–4]. ISR of DES, however, still tends to occur in some cases. The causes for ISR include; inadequate stent expansion, inadequate coverage of the lesion, stent mal-apposition, stent thrombosis, etc [5–7]. Recently stent fracture has been reported to be one of the significant factors of DES restenosis [8–12], however, the interval to the occurrence of stent fracture is still unknown. This report documents an impressive case of an immediate stent fracture after the implantation of a sirolimus-eluting stent (SES).

Late giant coronary aneurysm associated with a fracture of sirolimus eluting stent: A case report

A 73-year-old female underwent percutaneous coronary intervention (PCI) because of stable angina. An elective PCI for the RCA lesion was first performed with deploying sirolimus eluting stents (SES). Three weeks later, PCI was also provided in the residual LAD lesion. Eight months later, she presented with new angina. CAG revealed an in-stent restenosis in the mid LAD and a large eccentric saccular coronary aneurysm (17 mm x 9 mm) at the proximal RCA. Intravascular ultrasound (IVUS) showed absence of stent struts around the orifice of aneurysm, which suggested a fracture of SES stent. The entry of coronary aneurysm was finally sealed with a polytetrafluoroethylene-covered stent. This report documented a rare case of late giant coronary artery aneurysm associated with a fracture of SES.

Clinical characteristics of stent fracture after sirolimus-eluting stent implantation

Background Despite several case reports of sirolimus-eluting stent (SES) fracture and concern regarding restenosis after successful SES implantation, the clinical characteristics of this problem are not well known. Methods Clinical records and angiographic films of patients who received follow-up coronary angiography between February 2005 and October 2006 were retrospectively analyzed. Results Among the 686 SES implanted in 479 patients, 27 fractures were found in 22 (3.2%) stents in 18 patients. All stent fractures occurred in long stented segments, i.e. ≥ 28 mm (range, 28 mm to 83 mm). Of the 22 fractured stents, sixteen (72.7%) were identified in the right coronary artery (RCA) and fifteen (68.2%) were found to have a fracture site within 10 mm from areas with increased rigidity due to metal overlap. The significant multivariate predictors of stent fracture were the stented length (Odds ratio 1.06; 95% confidence interval 1.04–1.09; p = 0.001) and the RCA location (Odds ratio 4.44; 95% confidence interval 1.66–11.86; p = 0.003). The binary restenosis rate was 22.7% and target lesion revascularization was performed in two (9.1%) fractured stents. Conclusions SES fracture was associated with a long stented segment, RCA location and metal overlap. Stent fracture may be another potential risk factor for restenosis after successful SES implantation.

A Sirolimus-Eluting Stent Fracture Combined with a Coronary Artery Aneurysm

A stent fracture combined with a coronary artery aneurysm is a rare event. As these events can lead to a harmful outcome, such as the development of myocardial ischemia by in-stent restenosis or thrombosis, repeated coronary intervention may be required. We report a case of a stent fracture combined with a coronary artery aneurysm. The fracture was thought to have developed by mechanical stress produced from a change of regional wall motion after an anteroseptal myocardial infarction. As detected by the use of intravascular ultrasound, neither in-stent restenosis nor a thrombus in the fractured stent was present. A cardiac magnetic resonance image showed that no viable myocardium in the anteroseptal wall was present. Therefore, the patient underwent medical treatment without intervention of the fractured stent. (Korean Circ J 2008;38:69-71)

Abstract 2156: In-Stent Restenosis after Sirolimus-Eluting Stent Implantation is Related to Coronary Stent Fracture

Background and objectives : It has been reported in few studies about relationship between sirolimus-eluting stent (SES) fracture and in-stent restenosis (ISR). Therefore, authors investigated clinical characteristics of the SES fracture and the association with ISR. Subjects and Methods : From December 2003 to February 2006, implantation and follow-up coronary angiography(CAG) for 796 sirolimus-eluting stents were carried out in Severance hospital. We reviewed clinical, procedural and structural factors which might affect SES fracture and ISR. Results : Twenty four fractures after 796 SES implantation were identified by follow-up coronary angiography, sixteen cases in the left anterior descending artery and eight in the right coronary artery. The median time interval from stent implantation to follow up CAG was 9.0 months [range: 2 ~ 30 months]. No statistical difference was found in stent diameter (fracture group 3.06 ± 0.32 mm vs non-fracture group 3.08 ± 0.31 mm, P=0.778). Length of fractured stents was longer than non-fractured stents (30.29 ± 4.16 mm vs 24.51 ± 6.18 mm, P&lt;0.001). The binary ISR rate in the stent fracture group was higher compared to non-fracture group (50% vs 4.4%, p &lt; 0.001). Predictors for ISR estimated by multivariate analysis were stent fracture (OR=33.6, p &lt; 0.001), stent diameter less than 3.0 mm (OR=2.84, p =0.015) and stent length over 28 mm (OR = 3.10, p = 0.023). Among twelve cases which had both binary restenosis and stent fracture, eight cases were treated by balloon angioplasty or additional stent implantation considering the condition of patients. Conclusion : Stent fracture may be one of the crucial mechanisms of ISR after implantation of SES. However, further studies in larger scale are required to define the incidence, predisposing factors, and clinical outcomes of SES fracture.

Very Late Stent Fracture Associated With a Sirolimus-eluting Stent

Late stent thrombosis (>1 year after implantation) is a recognised complication involving drug-eluting stents. Stent fracture is increasingly being reported as a complication of drug-eluting stent, and in particular sirolimus-eluting stent use. We report the case of very late sirolimus-eluting stent fracture resulting in an acute coronary syndrome. This case report highlights the need for greater awareness and post-marketing surveillance to detect a potential mechanism for late stent thrombosis in the drug-eluting stent era.

Very Late Stent Thrombosis Related to Fracture of a Sirolimus-Eluting Stent

Although late stent thrombosis is a very rare complication after a drug-eluting stent implantation, this could induce significant sequelae. Several mechanisms for very late stent thrombosis have been suggested. We experienced a new possible mechanism of very late stent thrombosis after the implantation of a sirolimus-eluting stent. A sirolimus-eluting stent fracture might induce mechanical injury of the endothelium and then thrombotic occlusion at 24 months after the stent procedure. (Korean Circulation J 2007;37:385-387)

Drug-eluting stent fracture occurred within 2 days after stent implantation

Recently the cases of stent fracture after sirolimus-eluting stent (SES) implantation have been reported in the real world. All of them were found several months later during the follow-up of coronary angiogram (CAG), and some were related to in-stent restenosis (ISR). We report a case of stent fracture after percutaneous coronary intervention (PCI) with SES within 2 days after stent implantation. Further investigation is required to elucidate the mechanism and clinical significance of stent fracture of SES.