CORRESPONDENCE: LETTER TO THE EDITOR
Life-Threatening Coronary Artery Spasm Following Sirolimus-Eluting Stent Deployment
Stephen Wheatcroft, PhD, MRCP,
Jonathan Byrne, PhD, MRCP,
Martyn Thomas, MD, FRCP and
Philip MacCarthy, PhD, MRCP*
* King’s College Hospital, Cardiology, Bessemer Road, Denmark Hill, London, SE6 9RS, United Kingdom (Email: philip.maccarthy{at}kingsch.nhs.uk).
We were interested to read the report by Togni et al. (1), with its accompanying editorial (2), on paradoxical coronary vasoconstriction associated with sirolimus-eluting stents (SESs). We would like to report a case of life-threatening coronary artery spasm following drug-eluting stent deployment. A 55-year-old man was recently treated in our department after presenting with recurrent ischemic symptoms. He first presented with angina in August 2003, when a proximal stenosis of the right coronary artery was treated with a paclitaxel-eluting stent (Conor Medsystems, Menlo Park, California) as part of a clinical trial. He developed further exertional angina in May 2004, when angiography revealed restenosis of the right coronary artery stent. This was treated by cutting balloon dilation followed by intracoronary brachytherapy with a 60-mm beta-emitting source (BetaCath, Novoste, Norcross, Georgia).
In November 2004 he presented with unstable angina when coronary angiography confirmed recurrent restenosis at the proximal and distal edges of the original stent. This was treated by the direct deployment of SESs (Cypher Select, Cordis Europa NV, Amersfoort, the Netherlands), overlapping the existing stent proximally and distally. Four hours after stent deployment, the patient developed chest discomfort associated with ventricular fibrillation. After successful defibrillation, he returned immediately to the catheterization laboratory, where repeat angiography showed the right coronary artery to be patent (Fig. 1). Within minutes of this diagnostic image, however, the patient developed further chest pain associated with ST-segment elevation in the inferior leads. Prompt repeat angiography at this stage confirmed occlusive spasm of the right coronary artery distal to the SES (Fig. 2). This improved following intracoronary nitrate administration (Fig. 3). As we believed the severe spasm in this region to be the cause of the earlier ventricular fibrillation, we elected to deploy a paclitaxel-eluting stent (Taxus Express, Boston Scientific, Marlborough, Massachusetts) to cover the vasospastic arterial segment (Fig. 4). An excellent angiographic result was achieved, and the patient has remained asymptomatic at follow-up.
This case illustrates that occlusive coronary spasm may develop after drug-eluting stent deployment with potentially life-threatening consequences. We can only speculate whether the abnormal vasomotion in the arterial segment distal to the SES was attributable to a local effect of sirolimus on endothelial function (3), or to late endothelial dysfunction following brachytherapy (4). The history of prior treatment of the vessel with paclitaxel may also be relevant. Nonetheless, the potential for drug-eluting stents to unfavorably alter coronary vasomotion is worthy of further study.
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References
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1. Togni M, Windecker S, Cocchia R, et al. Sirolimus-eluting stents associated with paradoxic coronary vasoconstriction J Am Coll Cardiol 2005;46:231-236.[Abstract/Free Full Text]2. Serry R, Penny WF. Endothelial dysfunction after sirolimus-eluting stent placement J Am Coll Cardiol 2005;46:237-238.[Free Full Text] 3. Jeanmart H, Malo O, Carrier M, Nickner C, Desjardins N, Perrault LP. Comparative study of cyclosporine and tacrolimus vs newer immunosuppressants mycophenolate mofetil and rapamycin on coronary endothelial function J Heart Lung Transplant 2002;21:990-998.[CrossRef][Web of Science][Medline] 4. Togni M, Windecker S, Cocchia R, et al. Deleterious effect of coronary brachytherapy on vasomotor response to exercise Circulation 2004;110:135-140.[Abstract/Free Full Text]
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