1. Interesting Case Presentation
Mohammed Balghith, MD, FACC,FRCPC,FACP
Director of Cath Lab, King Abdulaziz Medical City
King Abdulaziz Cardiac Center, National Guard ,Riyadh, SA
KACC

2. Mohammed Balghith, MD DISCLOSURES
I have no real or apparent conflicts of interest to report.

3. History and Managment :
67 y old female patient known to have DM and HTN,
Had ACS in 2006 , underwent PCI and DES in LAD using 2.5 x 13 Cypher stent and RCA using Cypher stent 3.5 x 23mm overlapped with 3x23 Cypher in Nov 2006.

11. LAD Before and after PCI in 2006

12. RCA before and after PCI in 2006

13. History and Managment
in April she was admitted with Anterior STEMI after discontinuation of clopidogrel , patient was given tPA in another hospital
She sarted to have mild SOB and CCS class II angina
Pt was admitted electively to our hospital for coronary angiogram

22. Hospital course in 2009
Coronary angiogram, showed a recanalized LAD stent, and collaterals from LCA to distal RCA.
Selective angiogram of RCA showed a complete fractured proximal Cypher stent in two separate segments , associated with CTO and aneurysm in the gap between fractured segment and this was confirmed by IVUS during cath
PTCA , was done after Few trials using CTO wires and could not go through this occlusion between the fractured stent , which could be due to disconfiguration of this segment , change of angle and the chronicity of the lesion

23. Balloon Angioplasty and the lesion was crossed by passing the wire through the aneurismal segment down to distal artery ,achieving a good flow and final results
Cardiac CT scan was done which confirm the same findings of RCA stent fracture
Echocardiogram showed reduction in ejection fraction from 55% to 35%
patient was clinically very stable and discharged after PTCA on optimal medical therapy

24. Complete fracture of RCA Stent , CTO and aneurysm formatiom 2009

25. IVUS showing the stent and surrounding aneurysem

26. RCA before and after PTCA 2009

27. Cardiac CT scan few days later

28. Cardiac CT scan few days later
Cardiac CT scan confirming the stent fracture

29. Take Home Message
Stent fracture is one of the possible causes of in-stent restenosis after Drug eluted stent (DES).
Sirolimus eluting stent (Cypher) is the most common stent associated with stent fracture which is affected by mechanical stress provoked by rigid structures and hinge points.
This leads to high incidence of target vessel revascularization

30. Take Home Message
Stent fracture mostly associated with Cypher stent, this case was associated with both CTO and aneurysm. The diagnosis was made by Coronary angiogram and confirmed by Cardiac CT-Scan
Therefore Cardiac CT-scan might be used as non-invasive tool to diagnose suspected cases