title: In-stent restenotic lesions can rupture--a case against plaque sealing.
abstract: We present a case of plaque rupture located inside a restenotic stent. Intravascular ultrasound defined a lesion with a minimal lumen area (MLA) of 3.59 cm², plaque burden of 72%, and reference vessel luminal diameter of 4.0 mm with an external elastic membrane lumen cross-section area of 12.6 mm². There was a clearly identified plaque rupture, with a flap-like dissection within the stented segment. Virtual histology intravascular ultrasound confirmed that the adjacent plaque had necrotic core with a thin overlying fibrous cap. The remaining tissue next to the dissection plane was fibrotic. This case illustrates that neointimal hyperplasia may organize into an unstable plaque, with a thin fibrous cap overlying a lipid-rich necrotic core-a so-called virtual histology thin-capped fibroatheroma. As defined in the PROSPECT trial, the in-stent stenotic lesion in our case conformed to the definition of a high-risk plaque-it had an MLA < 4 mm², plaque burden was ≥ 70%, and there was >10% necrotic core. It became unstable and ruptured. The demonstrated findings of this case may sway physicians against sealing hemodynamically nonsignificant unstable plaques.
authors.affiliation: Vancouver General Hospital, Vancouver, British Columbia, Canada.
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Hoole
authors.forename: Andrew
authors.initials: A
authors.lastname: Starovoytov
authors.forename: Jaap N
authors.initials: JN
authors.lastname: Hamburger
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation*; D017023:Coronary Angiography; D023903:Coronary Restenosis / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy; D054855:Drug-Eluting Stents; D005260:Female; D005355:Fibrosis; D006801:Humans; D006965:Hyperplasia; D009203:Myocardial Infarction / Q000628:therapy*; D009336:Necrosis; D012422:Rupture, Spontaneous; D015607:Stents; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional