A Patient with Repeated Catastrophic Multi-Vessel Coronary Spasm after Zotarolimus-Eluting Stent Implantation
A 42-year-old man was admitted to Chonnam National University Hospital (Gwangju, Korea) for acute chest pain. He was an ex-smoker with a 20 pack-years history, but he didn't have any other significant past-medical history such as dyslipidemia, diabetes or hypertension. He had been on regular anti-anginal medication over the past two years since he underwent pecutaneous coronary intervention (PCI) with a 2.75×18 mm zotarolimus-eluting stent (Endeavor Resolute®, Medtronic vascular, Santa Rosa, CA, USA) in the mid-left anterior descending artery (LAD) due to unstable angina pectoris ().\nTwo months after the stent implantation, he developed severe chest pain. The 12-lead electrocardiogram (ECG) on admission showed atrial fibrillation and new onset ST-segment elevation in lead aVR with ST-segment depression in multiple other leads, suggesting a left main coronary artery disease (). During the initial evaluation in emergency room, he developed pulseless ventricular tachycardia, which was successfully resuscitated with electric countershock. A coronary angiogram (CAG) after the resuscitation showed severe multi-vessel spasm with near total occlusion of the proximal LAD, proximal left circumflex artery and mid-right coronary artery (RCA) with a patent previously implanted stent in the mid-LAD (). The spasm was completely relieved by intracoronary nitroglycerin injection (). A calcium channel antagonist and oral nitrate were added to anti-anginal medication after recovery.\nTwo years after index PCI, he again compained of severe squeezing chest pain despite the continued use of anti-anginal medications including nitrate and calcium channel antagonists. He was again admitted to the hospital. An ECG on admission showed ST depression and T wave inversion on the lateral leads; however, the cardiac enzymes were within normal limits. CAG revealed severe vasospasm in the proximal and distal LAD, and mid-RCA (). Intracoronary administration of nitroglycerin relieved the vasospasm, but there was de novo stenosis in the proximal LAD at the proximal edge of the previously implanted zotarolimus-eluting stent (). The intravascular ultrasound (IVUS) showed a large amount of plaque (minimal lumen area: 3.7 mm2, plaque burden: 55%), for which stenting was performed using a 3.0×24 mm everolimus-eluting stent (Promus Element, Boston scientific, Natick, MA, USA) (). The final CAG and IVUS showed good distal flow without residual stenosis (). After an uneventful recovery, he was discharged with medication for coronary vasospasm including a dual calcium channel antagonist, nitrate, and statin.