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Very Late Thrombus NSTEMI Due to Malapposition

A 48-year-old male ex-smoker with a history of hyperlipidemia presented with NSTEMI. Patient had a prior PCI to the mid LAD two years prior the event in an outside hospital. Coronary angiography before PCI showed a hazy lesion in the proximal LAD (Figure 1A, B, arrow), which was further examined using OCT.
OCT imaging of the proximal LAD detected a large red thrombus in the previously implanted stent within its proximal edge (Figure 2A, B asterisks) and stent edge strut malapposition behind the thrombus In Figure 2A and C (arrows point to the stent struts covered with tissue).
Balloon dilatation was performed at the proximal edge of the stent using a 4.5mm noncompliant balloon based on the vessel size determined by OCT, but post-balloon OCT showed the presence of large malapposition at the proximal stent edge (Figure 3 arrows) of stent and residual red thrombus (Figure 3B asterisk).
Based on the OCT findings, a decision was made by the operator to implant an additional 5.0 x 12mm DES into the proximal LAD. Post-stent angiography showed satisfactory results, which were further verified by post-stent OCT pullback (Figure 4). OCT imaging confirmed successful thrombus removal with minor residual thrombus protrusion (Figure 4 C, arrow) and resolution of stent malapposition (Figure 4C-E). There was no stent edge dissection detected at the distal or proximal edge of the stent, minimal stent area was 12.5mm2 and percent stent expansion 87%.

In this case of NSTEMI with very late ST, OCT helped identify incomplete stent apposition as the cause of the event, select the most appropriate treatment strategy, and check whether optimal post-PCI targets were achieved at the end of the procedure.

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