Coronary edema demonstrated by cardiovascular magnetic resonance in patients with peri-stent inflammation and aneurysm formation after treatment by drug-eluting stents.

D rug-eluting stents (DES) minimized the occurrence of in-stent restenosis but with a penalty of increased risk of late stent thrombosis. 1 In patients with late stent thrombosis, adverse vessel wall reactions such as uncovered and malap-posed stent struts, coronary aneurysms, and accelerated neo-atherosclerosis 2 have been identified. The stent polymer is suspected to induce an inflammatory response, 3 resulting in vessel wall abnormalities. Identification of patients with an inflammatory response to DES might be essential in preventing late stent thrombosis. Inflammatory processes increase vessel wall permeability, leading to edema, and both native and peri-stent vessel wall inflammation may be associated with tissue edema. Cardiovascular magnetic resonance (CMR) performed with a T 2-weighted short-τ inversion recovery sequence (T 2-STIR) has recently been shown to identify localized coronary edema in the culprit artery of patients with acute myocardial infarction. 4 Parameters for the ECG-triggered, navigator-gated, dark-blood, T 2-STIR fast-spin-echo sequence were as follows: repetition time, 2 RR intervals; echo time, 100 milliseconds; echo train length, twenty 0.68×0.68×8-mm 3 voxels; and 2 signal averages. Here we present 3 patients treated with DES (Cypher Select+, Cordis, Johnson & Johnson, Miami Lakes, FL) who demonstrate peri-stent edema as a possible marker of stent-induced coronary inflammation. A 41-year-old woman experienced very late stent thrombosis 15 months after treatment with DES in the proximal left anterior descending artery (LAD). Coronary angiography showed peri-stent staining in the proximal LAD (Figure 1, left), suggestive of adverse vessel wall reaction. Frequency-domain optical coherence tomography (C7, St. Jude Medical, St. Paul, MN) showed coronary aneurysms in the stented area of the LAD with several thrombi (Figure 1C, middle; Movie I in the online-only Data Supplement). T 2-STIR CMR demonstrated localized edema in the stented LAD area and in the native atherosclerotic coronary vessel wall at the proximal LAD and left main coronary artery, supporting an inflammatory cause (Figure 1A–1C, right). The patient was treated with dual antiplatelet therapy indefinitely. Follow-up was performed at 20 months to evaluate whether cessation of dual antiplatelet therapy before necessary, unrelated major surgery was safe. Progression of the vessel wall changes was detected (optical coherence tomography; Movie I in the online-only Data Supplement), and the patient was treated with bypass surgery. Histology of the peri-stent vessel wall verified infiltration by degranulating eosinophils (Figure 1G). A 42-year-old man was treated by DES in the LAD and first diagonal artery. Baseline study optical coherence tomography showed well-apposed …