全北醫大論文集第36卷第1號 2세대 약물 용출 관상동맥 스텐트 삽입 후 급성 심근 경색으로 병발한 관상동맥 연축 1예 전주 예수병원 순환기내과 김중근․이신은․박문식․윤소희․이나은․이재운 이동엽․박종필․전성희․임지현․류제영 A Case of Intractable Coronary Artery Spasm Lead to Myocardial Infarction Mimicking Acute Thrombosis after Second-Generation Drug-Eluting Coronary Stent Implantation Joong Keun Kim, Shin Eun Lee, Moon Sik Park, So Hee Yun, Na Eun Lee, Jae Un Lee, Dong Yub Lee, Jong Pil Park, Sung Hee John, Ji Hyun Lim, Jay Young Rhew Division of Cardiology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea = Abstract = Although several investigators have reported the coronary artery spasm after coronary artery stenting, all previous reports, coronary spasm after drug-eluting stent (DES) placement was occurred in first generation DES, such as sirolimus-eluting (Cypher®) and ® paclitaxel-eluting stents (Taxus ). Clinical relevance is unknown, the underlying mechanism may be delayed vascular healing due to toxic effects of the sirolimus and paclitaxel to endothelial cells (EC). The second-generation DES, such as everolimus-eluting (Xience V®) ® and zotarolimus-eluting stents (Endeavor ), are proving to be significantly more effective and safer than the first-generation DES.1)2) We report a patient with severe coronary artery spasm lead to myocardial infarction after second generation DES implantation at the site of detectable atherosclerotic lesion. (Key Words: Coronary artery vasospasm; Drug-eluting stents; Percutaneous transluminal coronary angioplasty.) changed the care of patients with coronary Introduction Drug-eluting stents have significantly artery disease and became the mainstream 교신저자: 이신은, 560-750 전북 전주시 완산구 서원로 68, 전주예수병원 순환기내과 Tel: 82-63-230-1343, Fax: 82-63-230-1309, E-mail: [email protected] - 45 - 2 全北醫大論文集第36卷第1號 of interventional cardiology practice, leading 3.0 x 18 mm everolimus-eluting stent to decreased neointimal proliferation and (Xience V®, Abbott, IL, USA) was successfully clinical restenosis.3) However, vascular deployed in the distal LCx and another 4.0 ® compatibility issues are reported about x 15 mm Xience V persistent abnormal vasomotor responses the proximal RCA. We decided to perform 4) in the drug-eluting stented vessel. stent was placed to We staged percutaneous coronary intervention herein report a case with severe coronary (PCI) for diffuse long lesion of LAD as artery spasm lead to myocardial infarction the cause of renal insufficiency of his after second generation coronary artery clinical state. After two days later, we stenting, which did not relieved despite performed coronary angioplasty of proximal high-dose intracoronary nitroglycerin and to mid LAD with two 3.0 x 28 mm, 3.5 x nicorandil injection. 28 mm Xience V® stents sequentially with overlapping. And then, post-kissing balloon angioplasty was performed using 3.5 x 15 Case mm, 2.0 x 15 mm balloon for LAD, first A 65-year-old man with a history of diagonal branch simultaneously. Final hypertension was taken to the emergency angiography showed excellent result (Fig. department because of severe squeezing chest 2). At the next dawn, half a day after pain for four hours. His electrocardiography PCI, he complained of severe chest pain (ECG) showed normal sinus rhythm and with diaphoresis. The pain was not relieved no significant ST-segment changes. His by administration of sublingual nitroglycerin, cardiac elevated and his ECG showed new ST-segment [Creatine phosphokinase (CPK): 424 U/L, elevation in the anterior precordial leads CK-MB: 13.5 ng/ml, Troponin I: 1.55 ng/ml]. (Fig. 3). Then the patient was taken to Transthoracic echocardiography demonstrated catheterization laboratory immediately with akinesia of the basal inferolateral and a preliminary diagnosis of acute stent mid-inferolateral wall with preserved left thrombosis. The repeat CAG revealed no ventricular function. Emergency coronary definitive stent thrombosis in proximal-to-mid angiography (CAG) revealed distal left LAD, but diffuse vasospastic near total circumflex artery (LCx) was totally occluded occlusion by thrombosis and proximal to mid left extending to distal LAD. coronary artery (LAD) had diffuse significant intra-coronary nitrate and nicorandil several stenosis involving ostium of large first times diagonal branch. Right coronary angiography intracoronary administration of high-dose showed significant stenosis of proximal vasodilators right coronary artery (RCA) (Fig. 1). A severe coronary spasm was suboptimally enzyme levels were - 46 - from during the thirty and end of the We injected minutes. enough stent time Despite interval,