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Multiple high-pressure dilatations were performed with a 3 mm non-compliant balloon&#44; with clear lumen improvement but still with a suboptimal angiographic result &#40;intrastent haziness with residual stenosis&#41;&#46; A 3&#46;0 mm bioresorbable vascular scaffold &#40;BVS&#41; &#40;Abbott Vascular&#44; Santa Clara&#44; CA&#44; USA&#41; was implanted and subsequently postdilated with a 3&#46;25 mm non-compliant balloon at 20 bar&#44; with an excellent final angiographic result &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41;&#46; Repeat OCT disclosed a properly apposed and expanded device&#46; The characteristic image of the BVS struts &#40;box-like appearance without dorsal shadowing&#41; was clearly identified against the underlying residual neointimal or atherosclerotic tissue over the underlying metallic stent &#40;bright struts with clear-cut posterior shadow&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41;&#46; There was a moderate rise in cardiac enzymes &#40;peak high-sensitive troponin T 1115 ng&#47;l&#44; peak creatinine kinase 309 U&#47;l&#41; but the clinical course was uneventful and the patient was discharged on aspirin and prasugrel three days later&#46; Unfortunately&#44; three months later the patient himself decided to stop dual antiplatelet therapy&#46; After four days without medication&#44; he suffered a new anterior myocardial infarction&#46; Emergent coronary angiography revealed a thrombosis of the BVS&#44; which was successfully treated with thromboaspiration and dilatation with a non-compliant balloon &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B&#41;&#46; Six months later the patient remains asymptomatic with good adherence to treatment&#46; A scheduled coronary angiography at this time confirmed an excellent result in the target segment&#46; OCT showed a well expanded and apposed BVS with complete neointimal coverage &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>C and D&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0010" class="elsevierStylePara elsevierViewall">Very late stent thrombosis is a rare but devastating complication after percutaneous coronary revascularization&#46; Stent thrombosis may be due to a mechanical problem such as stent malapposition or underexpansion&#46; On the other hand&#44; pathological studies have demonstrated that neoatherosclerosis plays a major role in certain patients with very late stent thrombosis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Interestingly&#44; neoatherosclerosis occurs not only more frequently but also earlier in patients treated with drug-eluting stents compared with those treated with bare-metal stents&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> When the thrombosis is related to stent malapposition or underexpansion&#44; balloon angioplasty without stent deployment is sufficient in most cases&#46; However&#44; the therapy of choice for patients presenting with very late in-stent restenosis or very late stent thrombosis as a result of neoatherosclerosis remains unclear&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3</span></a> In this context the use of BVS is a potentially attractive strategy to avoid the implantation of an additional metal layer while ensuring an optimal acute result and benefiting from their unique antirestenotic efficacy&#59; in addition&#44; they may promote plaque stability and passivation of vulnerable plaques by providing a uniform homogeneous neointimal layer&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> In this regard&#44; some preliminary reports have suggested the value of BVS in patients with in-stent restenosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> However&#44; the use of BVS in patients with very late stent thrombosis has not been previously reported&#46; Currently&#44; neoatherosclerosis may be readily recognized using OCT at a resolution of 15 &#956;m&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> This technique is able to unravel the underlying pathological substrate in patients presenting with stent failure&#46; The unique insights provided by OCT may help to tackle underlying mechanical problems such as stent malapposition or underexpansion and neoatherosclerosis&#44; and also to optimize BVS deployment&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Our findings suggest the value of BVS for the treatment of selected patients suffering from very late stent thrombosis as a result of neoatherosclerosis&#46; However&#44; only prospective studies will be able to establish the potential role of this novel form of therapy in this challenging anatomic scenario&#46; In addition&#44; the subsequent episode of BVS thrombosis&#44; which in our case was closely related to lack of adherence to prescribed medications&#44; reminds us of the important role of patient education and counseling to ensure the maintenance of appropriate dual antiplatelet therapy&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Case report
Bioresorbable vascular scaffold for very late stent thrombosis resulting from ruptured neoatherosclerosisBioresorbable vascular scaffold for very late stent thrombosis
Plataformas biorreabsorbíveis no tratamento da trombose de stent muito tardia resultante de rotura de neoaterosclerose
Teresa Bastante, Fernando Rivero, Javier Cuesta, M. Cruz Aguilera, Daniel Rodríguez, Amparo Benedicto, Fernando Alfonso
Corresponding author
falf@hotmail.com

Corresponding author.
Cardiac Department, Hospital Universitario de La Princesa, Madrid, Spain
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Multiple high-pressure dilatations were performed with a 3 mm non-compliant balloon&#44; with clear lumen improvement but still with a suboptimal angiographic result &#40;intrastent haziness with residual stenosis&#41;&#46; A 3&#46;0 mm bioresorbable vascular scaffold &#40;BVS&#41; &#40;Abbott Vascular&#44; Santa Clara&#44; CA&#44; USA&#41; was implanted and subsequently postdilated with a 3&#46;25 mm non-compliant balloon at 20 bar&#44; with an excellent final angiographic result &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41;&#46; Repeat OCT disclosed a properly apposed and expanded device&#46; The characteristic image of the BVS struts &#40;box-like appearance without dorsal shadowing&#41; was clearly identified against the underlying residual neointimal or atherosclerotic tissue over the underlying metallic stent &#40;bright struts with clear-cut posterior shadow&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41;&#46; There was a moderate rise in cardiac enzymes &#40;peak high-sensitive troponin T 1115 ng&#47;l&#44; peak creatinine kinase 309 U&#47;l&#41; but the clinical course was uneventful and the patient was discharged on aspirin and prasugrel three days later&#46; Unfortunately&#44; three months later the patient himself decided to stop dual antiplatelet therapy&#46; After four days without medication&#44; he suffered a new anterior myocardial infarction&#46; Emergent coronary angiography revealed a thrombosis of the BVS&#44; which was successfully treated with thromboaspiration and dilatation with a non-compliant balloon &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B&#41;&#46; Six months later the patient remains asymptomatic with good adherence to treatment&#46; A scheduled coronary angiography at this time confirmed an excellent result in the target segment&#46; OCT showed a well expanded and apposed BVS with complete neointimal coverage &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>C and D&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0010" class="elsevierStylePara elsevierViewall">Very late stent thrombosis is a rare but devastating complication after percutaneous coronary revascularization&#46; Stent thrombosis may be due to a mechanical problem such as stent malapposition or underexpansion&#46; On the other hand&#44; pathological studies have demonstrated that neoatherosclerosis plays a major role in certain patients with very late stent thrombosis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Interestingly&#44; neoatherosclerosis occurs not only more frequently but also earlier in patients treated with drug-eluting stents compared with those treated with bare-metal stents&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> When the thrombosis is related to stent malapposition or underexpansion&#44; balloon angioplasty without stent deployment is sufficient in most cases&#46; However&#44; the therapy of choice for patients presenting with very late in-stent restenosis or very late stent thrombosis as a result of neoatherosclerosis remains unclear&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2&#44;3</span></a> In this context the use of BVS is a potentially attractive strategy to avoid the implantation of an additional metal layer while ensuring an optimal acute result and benefiting from their unique antirestenotic efficacy&#59; in addition&#44; they may promote plaque stability and passivation of vulnerable plaques by providing a uniform homogeneous neointimal layer&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> In this regard&#44; some preliminary reports have suggested the value of BVS in patients with in-stent restenosis&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> However&#44; the use of BVS in patients with very late stent thrombosis has not been previously reported&#46; Currently&#44; neoatherosclerosis may be readily recognized using OCT at a resolution of 15 &#956;m&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> This technique is able to unravel the underlying pathological substrate in patients presenting with stent failure&#46; The unique insights provided by OCT may help to tackle underlying mechanical problems such as stent malapposition or underexpansion and neoatherosclerosis&#44; and also to optimize BVS deployment&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Our findings suggest the value of BVS for the treatment of selected patients suffering from very late stent thrombosis as a result of neoatherosclerosis&#46; However&#44; only prospective studies will be able to establish the potential role of this novel form of therapy in this challenging anatomic scenario&#46; In addition&#44; the subsequent episode of BVS thrombosis&#44; which in our case was closely related to lack of adherence to prescribed medications&#44; reminds us of the important role of patient education and counseling to ensure the maintenance of appropriate dual antiplatelet therapy&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Very late stent thrombosis is a rare but devastating complication after percutaneous coronary revascularization&#46; Pathological studies have demonstrated that neoatherosclerosis plays a major role in certain patients with very late stent thrombosis&#46; Optical coherence tomography is able to unravel the underlying pathophysiology and may be used to select the best treatment option&#46; This case report describes the use of a bioresorbable vascular scaffold &#40;BVS&#41; in a patient suffering from very late stent thrombosis due to a complicated plaque in the setting of intrastent neoatherosclerosis&#46; To our knowledge&#44; this therapeutic strategy has not been previously reported in patients suffering from very late stent thrombosis&#46; In this scenario&#44; BVS implantation might represent an attractive strategy in selected patients&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A trombose de <span class="elsevierStyleItalic">stent</span> muito tardia &#233; uma complica&#231;&#227;o rara mas preocupante ap&#243;s a revasculariza&#231;&#227;o coron&#225;ria percut&#226;nea&#46; Estudos patol&#243;gicos t&#234;m demonstrado que a neoaterosclerose desempenha um papel importante em doentes selecionados com trombose de <span class="elsevierStyleItalic">stent</span> muito tardia&#46; A tomografia de coer&#234;ncia &#243;tica contribui para a compreens&#227;o da fisiopatologia subjacente&#44; permitindo selecionar a melhor op&#231;&#227;o de tratamento&#46; No presente caso descrevemos a utiliza&#231;&#227;o de um <span class="elsevierStyleItalic">stent</span> vascular bioabsorv&#237;vel num doente que apresentava trombose de <span class="elsevierStyleItalic">stent</span> muito tardia devido a placa complexa no contexto de neoaterosclerose intrastent&#46; De acordo com a nossa experi&#234;ncia&#44; esta estrat&#233;gia terap&#234;utica n&#227;o tem sido apresentada em doentes com trombose de <span class="elsevierStyleItalic">stent</span> muito avan&#231;ada&#46; Neste cen&#225;rio&#44; a implanta&#231;&#227;o de suportes vasculares bioabsorb&#237;veis pode representar uma estrat&#233;gia atrativa em doentes selecionados&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Coronary angiography in cranial view showing the occluded left anterior descending coronary artery &#40;arrow&#41;&#59; &#40;B&#41; final angiographic result after bioresorbable vascular scaffold deployment&#59; &#40;C&#41; optical coherence tomography &#40;OCT&#41; image after thrombus aspiration showing heterogeneous intrastent tissue with large lipid pools &#40;&#43;&#41;&#46; Some stent struts are poorly detected due to attenuation&#46; There is also calcified tissue &#40;Ca&#41; surrounding some struts&#46; Note plaque rupture &#40;arrow&#41;&#59; &#40;D&#41; OCT image after thrombus aspiration showing residual red thrombus &#40;T&#41; in an area with complete neointimal coverage&#46; &#40;&#42;&#41; denotes wire artifact&#59; &#40;E&#41; 3D reconstruction of OCT image after thrombus aspiration with severe stenosis due to intrastent tissue &#40;c&#41; and residual red thrombus &#40;T&#41; &#40;d&#41;&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Optical coherence tomography &#40;OCT&#41; findings after bioresorbable vascular scaffold &#40;BVS&#41; implantation&#46; The device was fully expanded and apposed&#46; The metallic struts of the underlying stent are clearly detected &#40;posterior shadow&#41; in the far field&#59; &#40;B&#41; OCT findings during BVS thrombosis&#44; with large platelet-rich thrombus &#40;pT&#41; occupying the lumen and the characteristic box-like appearance of the BVS struts&#59; &#40;C&#41; OCT after six months&#46; Notice complete neointimal coverage of struts&#46; &#40;&#42;&#41; denotes wire artifact&#59; &#40;D&#41; 3D reconstruction of OCT image after six months&#46;</p>"
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Article information
ISSN: 21742049
Original language: English
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2022 September 34 29 63
2022 August 28 24 52
2022 July 39 42 81
2022 June 25 23 48
2022 May 24 30 54
2022 April 38 25 63
2022 March 34 40 74
2022 February 30 24 54
2022 January 35 18 53
2021 December 34 28 62
2021 November 47 35 82
2021 October 47 46 93
2021 September 48 26 74
2021 August 58 30 88
2021 July 33 23 56
2021 June 46 17 63
2021 May 48 29 77
2021 April 84 37 121
2021 March 62 20 82
2021 February 52 13 65
2021 January 24 13 37
2020 December 38 3 41
2020 November 44 15 59
2020 October 32 11 43
2020 September 44 12 56
2020 August 34 9 43
2020 July 48 11 59
2020 June 42 14 56
2020 May 41 7 48
2020 April 50 11 61
2020 March 33 9 42
2020 February 125 48 173
2020 January 37 4 41
2019 December 36 4 40
2019 November 37 7 44
2019 October 34 6 40
2019 September 14 6 20
2019 August 29 8 37
2019 July 44 9 53
2019 June 33 16 49
2019 May 35 9 44
2019 April 29 13 42
2019 March 108 10 118
2019 February 70 9 79
2019 January 69 6 75
2018 December 61 9 70
2018 November 99 9 108
2018 October 95 10 105
2018 September 30 8 38
2018 August 28 5 33
2018 July 14 1 15
2018 June 23 3 26
2018 May 27 4 31
2018 April 35 3 38
2018 March 32 5 37
2018 February 22 9 31
2018 January 15 8 23
2017 December 44 4 48
2017 November 19 6 25
2017 October 21 10 31
2017 September 20 5 25
2017 August 26 17 43
2017 July 25 9 34
2017 June 19 9 28
2017 May 23 4 27
2017 April 16 5 21
2017 March 47 37 84
2017 February 36 7 43
2017 January 36 7 43
2016 December 40 8 48
2016 November 35 4 39
2016 October 33 8 41
2016 September 24 3 27
2016 August 10 1 11
2016 July 15 9 24
2016 June 13 36 49
2016 May 20 7 27
2016 April 24 2 26
2016 March 11 21 32
2016 February 27 31 58
2016 January 34 10 44
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Revista Portuguesa de Cardiologia (English edition)
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