Stent Gap by 64-Detector Computed Tomographic AngiographyRelationship to In-Stent Restenosis, Fracture, and Overlap Failure
Harvey S. Hecht, MD*,
Sotir Polena, MD,
Vladimir Jelnin, MD,
Marcelo Jimenez, MD,
Tandeep Bhatti, DO,
Manish Parikh, MD,
Georgia Panagopoulos, PhD and
Gary Roubin, MD, PhD
Lenox Hill Heart & Vascular Institute, New York, New York
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Figure 2 A 63-Year-Old Female With Recurrent Atypical Chest Pain 6 Months After Placement of Overlapping Stents in the LAD
(A) Computed tomographic angiography (CTA) curved multiplanar reconstruction (MPR) reveals clear stent separation (arrow) consistent with fracture as well as luminal hypodensity consistent with neointimal hyperplasia. (B) Catheter angiography demonstrates mild in-stent restenosis (arrow). (C) Stent fracture is evident on a frame without contrast (arrows), but is not seen on a subsequent frame, D. (E) Cross sections obtained from the straightened MPR reveal a low HU of 192 at the separation site, incompatible with the presence of metallic stent material. Densities in the normal area were >400 HU. HU = Hounsfield units; LAD = left anterior descending coronary artery.
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Figure 3 A 58-Year-Old Asymptomatic Male 8 Months After Placement of Overlapping RCA Stents
(A) Two areas of separation are noted on the CTA curved MPR (arrows) as well as luminal hypodensity consistent with neointimal hyperplasia. (B) Catheter angiography reveals significant in-stent restenosis (ISR) (arrow). (C) A single noncontrast frame displays complete separation, which is not visible on any subsequent frames. (D) Cross sections obtained from the straightened MPR reveal partial absence of stent material with HU <300 at both sites (left, middle). The normal area reveals uniformly higher HU (right). Fx = fracture; RCA = right coronary artery; other abbreviations as in Figure 2.
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Figure 4 A 70-Year-Old Female With Exertional Dyspnea 1 Year After Implantation of a Stent in the Proximal LAD
(A) CTA curved MPR reveals a stent gap (arrow) associated with luminal hypodensity consistent with neointimal hyperplasia. Catheter angiography reveals only moderate ISR (B) and an intact stent in a noncontrast frame (C). (D) Cross sections obtained from the straightened MPR reveal partial absence of stent material and low HU at the gap site (right arrow) and intact stent with HU >400 in the normal area (left arrow). Abbreviations as in Figures 2 and 3.
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Figure 5 A 36-Year-Old Male With Atypical Chest Pain 18 Months After LAD Stent Implantation During an Acute Myocardial Infarction
(A) CTA curved MPR reveals 2 stent gaps (arrows) associated with severe luminal hypodensity consistent with total occlusion. Catheter angiography confirms the total occlusion (B, arrow); an intact stent is noted in a noncontrast frame (C). (D) Cross sections obtained from the straightened MPR reveal partial absence of stent material and low HU at the gap sites (right and left) and intact stent with HU >400 in the normal area (middle). Abbreviations as in Figure 2.
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Figure 6 A 62-Year-Old Male With Dyspnea 9 Months After Overlapping LAD Stent Implantation
(A) CTA curved MPR reveals obvious separation without ISR (arrow). (B) Catheter angiography revealed only mild ISR (top) and a single noncontrast frame suggested partial fracture (bottom) (arrows). (C and D) Cross-sectional analysis confirmed the gap with decreased HU (D, middle), compared with proximal (D, left) and distal (D, right) stent segments.
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Figure 7 A 59-Year-Old Male With Recurrent Angina 6 Months After Obtuse Marginal Stenting
(A) CTA curved MPR reveals a stent gap (arrow) without clear evidence for contrast, consistent with severe ISR. (B) Catheter angiography reveals critical ISR at a hinge point in systole (top, arrow) and diastole (bottom, arrow), and an intact stent in noncontrast systolic and diastolic frames (C, arrow). (D) Cross sections obtained from the straightened MPR reveal the "crush" pattern with partial absence of stent material and low HU at the gap site (right) and intact stent with high HU in the normal area (left). Abbreviations as in Figure 1.
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