Very late restenosis of a paclitaxel-eluting stent implanted to treat previous in-stent restenosis of a bare metal stent.

Unlike what was observed with brachytherapy,1 the use of drug-eluting stents (DES) has not been associated with the delayed intimal proliferation that characterises restenosis. A 12-month followup is recommended to define the need for revascularisation in DES.2 Restenosis 1 year after the implant is considered unusual. We present the case of a 77-year-old hypertensive male ex-smoker with diabetes and hypercholesterolemia who was admitted in April 2004 for an inferior infarction. He was treated with thrombolysis, showing signs of reperfusion. Twentyfour hours after being admitted, the patient presented post-infarction angina. A coronary angiography was performed, revealing single-vessel (distal right coronary artery) disease that was treated successfully with two conventional partially overlapping stents (Guidant MULTILINK ZETA 3.5×23 and 3.5×15, Abbott Laboratories). After 10 months without symptoms, he was readmitted on March 2005 for progressive unstable angina. Coronary angiography was repeated and in-stent restenosis was observed (Figure 1A), which was successfully treated with stent implantation of a paclitaxel-coated DES (TAXUS 3.5×32; Boston Scientific, Natick, Massachusetts) (Figure 1B). Two years later (June 2007), he was readmitted for recurring atypical pain and another coronary angiography was performed that showed neither restenosis in the previously implanted DES or other significant coronary lesions (Figure 1C). The patient was discharged on treatment with aspirin, atorvastatin, beta-blockers, and angiotensinconverting enzyme inhibitors. There were no new events until November 2009 (more than 4 years after the DES implant) when the patient was readmitted for progressive unstable angina with a one-month evolution. Coronary angiography was repeated showing severe in-stent restenosis (Figure 1D), which was not present in the coronary angiography performed two years before. An intracoronary ultrasound study was performed (Figure 2) that showed proper stent expansion and apposition, and diffuse intimal hyperplasia and a minimal luminal area of 2.34 mm2, which confirmed the severity of the restenosis. This case is the latest DES restenosis reported in the literature. Restenosis appeared clinically four years after the implantation and angiographies showed that it had developed at least two years after the implant. The Bargiggia method considers that the MR velocity permits measurement of the intraventricular systolic pressure by applying a modified Bernoulli’s equation, making flow acceleration equal to the pressure generation velocity, dP/dt. To obtain dP/ dt, we measure the time that MR takes to accelerate from 1 to 3 m/s, corresponding to 4 and 36 mm Hg gradients, measuring dP/dt as the difference of the 2 gradients (32 mm Hg) divided by the time.3 This means that reducing the atrial pressure by equalising pressures and gradients and measuring an isovolumic phase parameter in patients in whom this does not exist. We can find cases where failure starts before the systole, as happens in the second beat in Figure 1, thus adding variability. Even with these limitations, this method of measuring dP/dt is closely correlated with the invasive value and is highly sensitive to changes in the inotropic state.3,4 Although it is essential that there be MR, it is common in patients with severe systolic dysfunction. Its use in studying alternans can be of great interest because it does not seem as affected by preload as is the aortic flow or the filling. It reflects overall ventricular function rather than an isolated segment and therefore eliminates the uncertainties brought about by tissue Doppler assessment, which although a useful technique for studying alternans,5 is affected by segmental contractility disorders and by ventilatory movements.