Article ID: CJ-18-0795
A 49-year-old man underwent percutaneous coronary intervention of the proximal left descending artery (LAD) and the distal left main bifurcation (Figure a,b). After pre-dilatation with 3.0-mm and 3.5-mm non-compliant (NC) balloons, intravascular ultrasound (IVUS) showed predominantly fibrotic plaque with partial mild calcification. Based on IVUS sizing, 3.0×25-mm and 3.5×15-mm Magmaris bioresorbable scaffolds (BRS; Biotronik, Buelach, Switzerland) were implanted with minimal overlap, followed by post-dilatation using 1:1 NC balloon at high pressure (18–22 atm; Figure c–f). Final IVUS confirmed optimal BRS results including symmetric expansion and apposition (Figure i–iv). Dual antiplatelet therapy with aspirin and clopidogrel was prescribed, to be continued for 3 years.
Serial coronary angiography (CAG) and intravascular ultrasound (IVUS). (a,b) Baseline CAG showing significant stenosis in the proximal left descending artery (LAD) and distal left main bifurcation. (c–f) Magmaris implantation and post-dilatation with 1:1 non-compliant balloons. (a’,b’) Final CAG at index percutaneous coronary intervention (PCI; blue dashed lines, lesions treated with Magmaris). (i–iv) IVUS at the proximal LAD treated with 3.0×25-mm Magmaris (i–iv correspond to I–IV, respectively). Scaffold area: (i) 6.70 mm2; (ii) 6.56 mm2; (iii) 6.75 mm2; (iv) 6.42 mm2. (A,B) CAG 2 months after PCI. (I–IV) IVUS at the segments with bioresorbable scaffold (BRS) struts collapsed toward the lumen (red arrowheads, collapsed BRS struts). Scaffold area: (I) 3.51 mm2; (II) 2.83 mm2; (III) 1.98 mm2; (IV) 3.27 mm2. (A’,B’) CAG after drug-eluting stent (DES) implantation (orange dashed lines, lesion treated with 3.0×33-mm DES). (I’–IV’) IVUS at the proximal LAD treated with DES (I’–IV’ correspond to I–IV, respectively). Scaffold area: (I’) 8.05 mm2; (II’) 8.31 mm2; (III’) 8.73 mm2; (IV’) 8.67 mm2.
Two months after the procedure, the patient presented with recurrent angina symptoms and underwent coronary angiography (CAG), showing luminal haziness with narrowing in the proximal LAD previously treated with the 3.0-mm Magmaris (Figure A,B). IVUS showed significantly collapsed BRS struts toward the lumen and mixed-echogenic tissue around the struts, suggesting thrombus formation (Figure I–IV; Supplementary Movie). After pre-dilatation, a 3.0×33-mm drug-eluting stent (DES) was implanted, sealing the collapsed BRS entirely, and post-dilated with 3.5-mm NC balloon. CAG showed excellent results and resolution of luminal haziness (Figure A’,B’). Post-procedural IVUS confirmed optimal DES expansion, completely covering the collapsed BRS without any materials protruding toward the lumen (Figure I’–IV’).
Favorable clinical outcomes after Magmaris implantation have been reported without scaffold thrombosis up to 2 years. In the present case, however, early dismantling of Magmaris implanted for simple stenotic lesions was noted, even with the specific implantation technique and optimal BRS results at the index procedure confirmed on IVUS. This phenomenon could be partially explained by the presence of concentric and thick fibrotic plaque causing BRS recoil and partially collapsing BRS during the bioresorption process before endothelialization.
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A.L. has served on the advisory board for Medtronic; and has received honoraria from Abbott Vascular. The other authors declare no conflicts of interest.
Supplementary Movie. Two-month follow-up intravascular ultrasound showing significantly collapsed bioresorbable scaffold struts toward the lumen and mixed-echogenic tissue around the struts, suggesting thrombus formation.
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http://dx.doi.org/10.1253/circj.CJ-18-0795