Editorial Comment

Stent Fracture: BrokenStents—Broken Hearts

Aristotelis C. Papayannis,1,2 MD

Emmanouil S. Brilakis,1,2 MD, PhD, FSCAI1Division of Cardiovascular Diseases, VA North TexasHealthcare System, Dallas, Texas2Division of Cardiovascular Diseases, University ofTexas Southwestern Medical Center, Dallas, Texas

Stent thrombosis is a catastrophic complication of

percutaneous coronary intervention (PCI) and has many

possible causes, such as stent underexpansion, stent

malapposition, and suboptimal antiplatelet therapy. In

this issue of the Journal, Lee et al. present a dramatic

case of stent thrombosis associated with fracture of a

Cypher sirolimus-eluting stent (Cordis, Warren, NJ) 3

years post-implantation in the right coronary artery [1].The incidence of stent fracture varies widely from

0.84% to 8.0%, although it may be underestimated dueto difficult angiographic visualization of the stents [2–4]. Most stent fractures are diagnosed >6 months afterimplantation and have variable presentation [4]: themajority of patients are asymptomatic, some presentwith recurrent angina due to in-stent restenosis, somewith an acute coronary syndrome [5] (occasionallywith stent thrombosis as in the present case) and some(very rarely) with cardiac tamponade and death due toaneurysm rupture [6]. Given the potentially cata-strophic complications associated with stent fracture,every effort should be undertaken to prevent it.

Stent fractures frequently occur in the right coronaryartery and in saphenous vein grafts (likely due to moreforceful and exaggerated motion), in angulated, long,and treated with overlapping stent lesions and inchronic total occlusions [4,7,8]. As in the present case,many stent fractures present late, possibly because ofmetal fatigue [8]. Most stent fracture cases have beenreported in patients receiving a Cypher stent, likelydue to its closed cell, thick-strut design, and its highradiopacity that facilitates visualization of the fracture.However, stent fractures have been observed with allstents including second generation drug-eluting stents[9,10]. As interventionalists, we have no control on theangiographic characteristics of the target lesion, butwe can customize the stent choice and deployment

strategy. Overexpansion of the stents should beavoided as it could weaken the struts and predispose tofracture. Since the Cypher stent is no longer availablefor clinical use, we are likely to encounter stent frac-tures less frequently, although stent fractures willlikely continue to be seen [9,10].Treating patients with stent fracture can be challeng-

ing. Wiring through the fractured segment may not bepossible, especially in cases of wide stent fragmentseparation or in cases of aneurysm formation, necessi-tating cardiac surgery. As seen in the present case, im-plantation of another stent may be required to restoreoptimal antegrade flow, yet this may also carry therisk for recurrent stent fracture [9]. Use of an endothe-lial progenitor cell capturing stent may improve endo-thelialization, but is also subject to the same risk forrecurrent metal fracture. Recurrent stent fracture shouldin most cases prompt referral for surgery. In the future,availability of bioabsorbable stents and improved metalstent alloy and designs will hopefully make stent frac-ture ‘‘a thing of the past.’’ Until then, awareness ofthis potential stent complication and routine use ofintravascular imaging in cases of in-stent restenosis,thrombosis, or aneurysm formation could help identifystent fracture and guide treatment decisions [3].

REFERENCES

1. Lee SW, Tam FC, Chan K. Very late stent thrombosis due to

DES fracture: Description of a case and review of potential

causes. Catheter Cardiovasc Interv 2011;78:1101–1105.

2. Umeda H, Kawai T, Misumida N, Ota T, Hayashi K, Iwase M,

Izawa H, Sugino S, Shimizu T, Takeichi Y, et al. Impact of siro-

limus-eluting stent fracture on 4-year clinical outcomes. Circ

Cardiovasc Interv 2011;4:349–354.

3. Doi H, Maehara A, Mintz GS, Tsujita K, Kubo T, Castellanos

C, Liu J, Yang J, Oviedo C, Aoki J, et al. Classification and

potential mechanisms of intravascular ultrasound patterns of

stent fracture. Am J Cardiol 2009;103: 818–823.

Conflict of interest: Dr Brilakis: Speaker honoraria from St Jude

Medical and Terumo; research support from Abbott Vascular and

Infraredx; spouse is an employee of Medtronic.

*Correspondence to: Emmanouil S. Brilakis, MD, PhD, Dallas VA

Medical Center (111A), 4500 South Lancaster Road, Dallas, TX

75216. E-mail: esbrilakis@yahoo.com

Received 8 October 2011; Revision accepted 10 October 2011

DOI 10.1002/ccd.23435

Published online 15 November 2011 in Wiley Online Library

(wileyonlinelibrary.com).

' 2011 Wiley Periodicals, Inc.

Catheterization and Cardiovascular Interventions 78:1106–1107 (2011)

4. Canan T, Lee MS. Drug-eluting stent fracture: incidence, con-

tributing factors, and clinical implications. Catheter Cardiovasc

Interv 2010;75:237–245.

5. Brilakis ES, Maniu C, Wahl M, Barsness G. Unstable angina

due to stent fracture. J Invasive Cardiol 2004;16:545.

6. Hoshi T, Sato A, Nishina H, Kakefuda Y, Noguchi Y,

Aonuma K. Fatal ostial right coronary artery coronary stent

fracture and perforation induced by mechanical stress between

the sternum and dilated aortic root. Circulation 2011;123:

1679–1682.

7. Kandzari DE, Rao SV, Moses JW, Dzavik V, Strauss BH,

Kutryk MJ, Simonton CA, Garg J, Lokhnygina Y, Mancini GB,

et al. Clinical and angiographic outcomes with sirolimus-eluting

stents in total coronary occlusions: the ACROSS/TOSCA-4

(Approaches to Chronic Occlusions With Sirolimus-Eluting

Stents/Total Occlusion Study of Coronary Arteries-4) trial.

JACC Cardiovasc Interv 2009;2: 97–106.

8. Nakazawa G, Finn AV, Vorpahl M, Ladich E, Kutys R, Balazs

I, Kolodgie FD, Virmani R. Incidence and predictors of drug-

eluting stent fracture in human coronary artery a pathologic

analysis. J Am Coll Cardiol 2009;54:1924–1931.

9. Almasood AS, Freixa X, Khan SQ, Seidelin PH, Dzavik V.

Stent fracture after everolimus-eluting stent implantation. Car-

diol Res Pract 2011;2011:320983.

10. Hussain ST, Arif I, Helmy T. Recurrent stent fracture: First

reported image of everolimus-eluting stent fracture leading to

recurrent restenosis in cardiac allograft vasculopathy. J Invasive

Cardiol 2010;22:617–618.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

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