Diagnosis and management of a patient with recurrent variant angina and history of percutaneous coronary intervention: vasospasm and percutaneous coronary intervention
Here we reported the case of an 80-year-old man with coronary artery disease, hypertension, and a 9-year history of percutaneous coronary intervention (PCI) with a sirolimus-eluting stent (SES) (Cypher, Cordis Corp., Miami Lakes, Florida, USA) in the proximal left anterior descending (LAD) artery. He was admitted to our department because of occurrence of chest pain at rest, with normal resting ECG and mild increase in troponin levels. The patient underwent urgent coronary catheterization demonstrating mild in-stent restenosis (ISR) in the proximal LAD and an intermediate stenosis in mid LAD (Fig. 1). To assess the functional impact of the stenoses on LAD, fractional-flow reserve was performed and a cumulative value for all stenoses of 0.84 was found (Fig. 2). Accordingly, the lesions were not treated by PCI. The patient was discharged on angiotensin-converting enzyme inhibitor, beta-blocker, clopidogrel, and statin. Three days after the discharge, the patient experienced a new episode of chest pain at rest, lasting 30 min with spontaneous regression. At admission, the patient was asymptomatic; however, during the in-hospital stay, he developed severe chest pain with a diffuse anterior ST-segment elevation (Fig. 3). The urgent coronary angiography revealed an occlusive vasospasm at the distal edge of the previously implanted SES (Supplementary material; Movie 1: Coronary angiogram showing the diffuse vasospasm on proximal LAD artery, http://links.lww.com/JCM/A114), which was promptly relieved by intracoronary administration of isosorbide dinitrate. We decided to perform intracoronary imaging using frequency-domain optical coherence tomography (FD-OCT, ImageWire; LightLab Imaging, Westford, Massachusetts, USA). FD-OCT confirmed the presence of a not critical ISR and demonstrated the presence of a plaque in the immediate vicinity of the distal edge of the stent (Fig. 4). A 3.0–23-mm everolimus-eluting stent (EES, Xience V; Abbott Laboratories, Abbott Park, Illinois, USA) was implanted at the site of the plaque, covering also the stent previously implanted, obtaining a good angiographic result. The patient was discharged home on angiotensin-converting enzyme inhibitor, beta-blocker, clopidogrel, and statin, and, at 9-month follow-up, he was free of symptoms and had no longer experienced chest pain at rest or during effort.