SS–10 Two Different Outcomes in One Week: RCA Stent Thrombosis, LAD DCB Success

Abstract

Introduction and Aim: A patient with a history of diabetes mellitus, hypertension, Parkinson's disease, and dementia, who had previously undergone stent implantation to the right coronary artery (RCA), was evaluated for chest pain. During elective coronary angiography, the lesion in the RCA was crossed with a guidewire, predilated with a 3.5×15 mm non-compliant (NC) balloon, and a 4.0×20 mm drug-eluting stent (DES) was implanted. Successful patency was achieved following post-dilatation with a 4.0×8 mm NC balloon.

Case Report: In the same session, after percutaneous transluminal coronary angioplasty (PTCA) was performed on the left anterior descending (LAD) artery lesion using 1.5×20 mm and 2.5×25 mm NC balloons, treatment was carried out with a 2.75×40 mm drug-coated balloon (DCB) at 7 atm pressure for 80 seconds. A successful angiographic result was obtained in the LAD at the end of the procedure. Approximately one week after the elective percutaneous coronary intervention (PCI), the patient presented to the emergency department with pronounced nausea, vomiting, and chest pain. Upon detecting changes consistent with an inferior myocardial infarction on the electrocardiogram, the patient was taken to the catheterization laboratory for emergency coronary angiography. Coronary angiography revealed stent thrombosis in the proximal RCA. The left main coronary artery was normal. In the LAD, the previously implanted proximal stent was patent, but a dissection was observed distal to the stent. The left circumflex (LCX) artery was dominant and showed widespread coronary artery disease. Notably, no significant early restenosis was observed in the LAD segment previously treated with the DCB. The thrombosed segment in the RCA was crossed with a guidewire. Sequential predilations were performed at high pressures reaching 20–26 atm using 2.5×12 mm, 2.75×20 mm, 3.0×12 mm, 4.0×12 mm, and 4.0×6 mm NC balloons. Following antithrombotic treatment, a 3.5×16 mm DES was implanted. Finally, successful angiographic patency was achieved after post-dilatation with a 4.0×6 mm NC balloon at 26 atm pressure. The most striking finding in this case is the thrombosis of the newly implanted RCA stent within just one week, clinically presenting as an inferior myocardial infarction. Stent thrombosis is a multifactorial complication. Mechanical factors such as under-expansion, malapposition, residual dissection, and complex coronary anatomy can play a major role, alongside the disruption of antiplatelet therapy. The patient experiencing severe nausea and vomiting prior to the myocardial infarction suggests that oral antiplatelet therapy compliance or gastrointestinal absorption may have been impaired. Failure to achieve adequate platelet inhibition, particularly in the early period post-stent implantation, poses a significant risk for stent thrombosis.

Conclusion: The second notable feature of this case is that the LAD segment, where a different revascularization strategy was applied in the same patient, remained patent in the early period. One of the major advantages of DCB therapy is the delivery of the antiproliferative drug to the vessel wall without leaving a permanent metal implant behind. The absence of early significant restenosis in the DCB-treated segment makes this case compelling in terms of early angiographic outcomes of DCB therapy versus stent thrombosis.