Incidence and Predictors of Drug-Eluting Stent Fracture in Human Coronary ArteryA Pathologic Analysis
Gaku Nakazawa, MD*,
Aloke V. Finn, MD ,
Marc Vorpahl, MD*,
Elena Ladich, MD*,
Robert Kutys, MS*,
Isidora Balazs, BS*,
Frank D. Kolodgie, PhD* and
Renu Virmani, MD*,*
* CVPath Institute, Inc., Gaithersburg, Maryland
Emory University School of Medicine, Atlanta, Georgia
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Figure 1 Representative Images of Stent Fracture and Calcification
(A) Grade I fracture of Taxus stent (single-strut fracture), grade II fracture of Cypher stent (multiple breaks but alignment is preserved), grade III fracture of Cypher stent (multiple breaks with deformation), grade IV fracture of Cypher stent (multiple breaks with transection but without gap), and grade V fracture of Cypher stent (total separation). Arrows indicate fractured stents. (B) Classification of calcification (mild: focal calcification; moderate: multiple sites of calcification; severe: >75% of stent length is associated with calcification). Arrows indicate areas of calcification.
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Figure 2 Distribution of Location of Stent Fracture in Nonoverlapping and Overlapping Stents
(A) Location of stent fracture in nonoverlapping stent. Note, the majority of stent fractures were localized in the middle of the stent body, except for stents >25-mm length where the fracture sites were slightly shifted toward the proximal end. (B) In overlapping stents, most fractures were observed within 5-mm distance from the overlapping zone with similar frequency in proximal and distal regions.
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Figure 3 A Case of Grade V Cypher and Taxus Stent Fracture (Case 1 in Table 3)
At 172 days following implantation the patient died from stent thrombosis in the left circumflex coronary artery (LCx). (A) Radiograph of the stented left circumflex and left obtuse marginal (LOM) artery. Note, presence of grade V Cypher stent fracture highlighted in magnified image (i) and another grade V fracture at the bifurcation site in the Taxus stent (ii). (B) Cypher stent in LOM with grade V fracture was associated with restenosis. (C) Taxus stent fracture in LCx was located in the area close to the bifurcation site where the thrombus was located (Thr). (D) The stented LCx segment distal to the fracture was widely patent.
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Figure 4 A Case of Grade V Cypher Fracture With Subacute Thrombosis (Case 3 in Table 3) 11 Days Following Implantation
(A) Radiograph of the left anterior descending coronary artery (LAD) shows an overlapping Cypher stent with grade V fracture located just distal to the overlapping site (highlighted in B). (C and D) Histologic sections of the overlapping stents showed well-expanded stent with propagated occlusive (thr) thrombus within the lumen. (E) The section taken at the fracture site showed an underexpansion of the stent with a platelet thrombus (thr) (inset). LM = left main coronary artery; OL = stent overlap region.
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Figure 5 A Case of Grade V Cypher Stent Fracture Not Associated With Any Complications (Case 7 in Table 3)
Patient died 570 days post-stent implantation from severe coronary artery disease. A complete separation was observed just proximal to the overlapping site, but histologic sections revealed patent lumen. (A) Radiograph of the LCx shows an overlapping Cypher stent with grade V fracture located just proximal to the overlapping site (highlighted in B). Histologic sections revealed well-expanded stents with a patent lumen of fracture site (C), overlapping stent site (D and E), and distal LOM section (F). Abbreviations as in Figure 3.
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