Everolimus

Abstract

Treatment failure: case report A man in his late 50s [exact age not stated] experienced treatment failure while receiving everolimus for the prophylaxis of thrombosis and coronary artery restenosis [dosages and routes not stated]. The man presented to hospital with complaints of chest pain for 3 days (at the age of 60 years; current presentation). Thirty six months prior to the current presentation, he had undergone treatment for unstable angina with a 3.5mm x 18mm bioresorbable vascular scaffold (BVS) everolimus-eluting bioresorbable scaffold [Abbott Vascular] in the proximal left anterior descending artery (LAD) for prophylaxis of thrombosis. At that time, coronary angiography showed significant stenosis in the proximal left anterior descending artery. Optical coherence tomography (OCT) showed optimal implantation of the bioresorbable vascular scaffold. Further, 20 months prior to his current presentation, he had been diagnosed with ST-segment elevation myocardial infarction associated with very late scaffold thrombosis. Coronary angiography image showed total occlusion of the proximal left anterior descending artery. OCT revealed a red thrombus associated with disruption of the scaffold strut. Therefore, revascularisation was successfully performed with drug-eluting stent (DES) comprising everolimus [Xience] 3.5mm x 33mm covering the whole segment of the previous scaffold for prophylaxis of coronary artery restenosis. At the time of current presentation, laboratory findings revealed the following: temperature 36.8°C, BP 130/80mm Hg, HR 66 beats per minute, RR 14 breaths per minute and oxygen saturation in room air 98%, while electrocardiography revealed Q-waves in precordial leads. Additionally, coronary angiography showed tight stenosis of the proximal LAD, which suggested DES-in-stent restenosis (ISR) on the previous BVS. OCT also showed plaque rupture and a disrupted scaffold strut in the neointimal proliferation of DES. He was finally diagnosed with unstable angina associated with restenosis of a DES on the previous BVS. Due to the development of thrombosis and coronary artery restenosis, treatment failure with everolimus was considered. Additionally, acute coronary syndrome secondary to DES-ISR on the previous BVS was considered. Therefore, he underwent a balloon angioplasty with drug-coated balloon (DCB) to treat the DES-ISR. After DCB placement, coronary angiography showed an acceptable residual stenosis of <10%. OCT revealed an achievement of optimal luminal gain. He was discharged on ticagrelor, aspirin and rosuvastatin, on the day following the procedure. He had an uneventful clinical course for 24 months. On follow-up 12 months later, the dose of ticagrelor was reduced.