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Multiple In-Stent Restenosis. A Rare Cause of Resistance to Antiproliferative Drugs?
The introduction of novel stent designs and implantation techniques represents a significant milestone in percutanious coronary intervention. Despite continuous technological progress, the incidence of in-stent restenosis remains relatively high. An uncommon cause of in-stent restenosis is resistance/hypersensibility to antiproliferative drug, and although rare, it can lead to devastating short- and long-term results.
We present the case of a 50-year-old male, with multiple cardiovascular risk factors, who is admited to the Institute of Cardiovascular Diseases in Iași, Romania, for stable angina. Following coronarography, a percutaneous coronary angioplasty is performed with a Sirolimus stent for a 80% right coronary stenosis. Short-term evolution is marked by recurrent angina with an increase in severity of native atherosclerotic plaques from the left coronary and a complete occlusion of the right coronary stent. Multistenting (using Sirolimus stents) of LM, LAD and LCX was performed. After three months, all Sirolimus stents were restenosed or completely occluded. The patient was referred for surgical revascularization. A month later, he was admitted with anterior MI, and LIMA graft as occlusion at the anastomosis site with LAD was noted. LM-LAD angioplasty was performed (with Sirolimus stent). Short-term evolution was marked by a second anterolateral MI followed by LM-LCX angioplasty with Everolimus stent. After one year, the patient had mild angina, and coronarography revealed a permeable LM-LCX Everolimus. Malignant in-stent restenosis following implantation of multiple stents with the same antiproliferative drug can be a significant indicator for a genetic resistance/hypersensibility. Although there are no markers to predict this entity, its incidence is very low, but it is associated with poor long-term outcomes.
Keywords: multistenting, resistance, hypersensibility, in-stent restenosis