revious randomized trials have shown that drugeluting stents (DES) are superior to bare-metal stents (BMS) in reducing the need for target lesion revascularization, but safety issues with DES have recently been raised. Case ReportIn February 2004, a 64-year-old man underwent percutaneous coronary intervention (PCI) for total occlusion of the proximal left anterior descending artery (LAD) using a 3.5×20 mm Tsunami stent™ (Terumo, Tokyo, Japan) under the diagnosis of subacute myocardial infarction. Routine follow-up coronary angiography at 6 months after PCI showed no in-stent restenosis, but there was significant stenosis of the mid-LAD bifurcation portion, so we deployed a 3.0× 33 mm Cypher stent™ (Cordis, Johnson & Johnson, New Brunswick, NJ, USA) inflated to 14 atm. Afterwards, the 2 nd diagonal branch (D2) of the LAD was compromised, so we dilated the lesion using a kissing balloon technique. Final coronary angiography showed no residual stenosis. That night, the patient suffered sudden severe anterior chest pain and the electrocardiogram (ECG) showed new T-wave inversion and ST-segment depression in the V3-6 leads. Emergency coronary angiography showed that the distal flow was good and the stent in the mid-LAD was patent, but D2 was compromised because of dissection. We deployed a 2.5×23 mm Cypher stent™ at 14 atm for D2, and then ballooned into the LAD with a reversed crush technique using a 3.0-mm balloon catheter. We performed a final kissing balloon dilation for the LAD and D2 (Fig 1). In March, 2005, repeat follow-up coronary angiography showed no in-stent restenosis, but there was mild peri-stent aneurysm Circulation Journal Vol.72, July 2008 formation in the mid-LAD. The patient had no cardiac symptoms during clinical follow-up after the second followup angiogram, and medical treatment was continued with aspirin 200 mg/day, a -blocker and a statin. In June 2007, the patient was admitted with gall stones and intestinal ileus. During treatment he stopped taking aspirin for 3 days and the next day, 35 months after Cypher™ stenting, he was taken to the emergency room because of severe squeezing chest pain for 1 h; the ECG showed tall T wave in the anterior wall (ie, regional wall motion abnormality) (Fig 2). The levels of cardiac enzymes were within the normal ranges [creatine kinase (CK): 36 U/L, CK-MB: 0.3 ng/ml, troponin I: 0.0 ng/ml]. Urgent coronary angiography revealed a patent BMS in the proximal LAD, but the sirolimus-eluting stents (SES) in the mid-LAD and D2 were totally occluded by massive thrombosis. Peri-stent aneurysmal dilation and 5-segment stent strut fractures were noted ( Figs 3A,B). We tried to cross the occlusion site using a guidewire, but were prevented by the severe displacement of the stent fracture Circ J 2008; 72: 1201 -1204 (Received September 19, 2007 revised manuscript received November 14, 2007; accepted December 11, 2007

A paradoxical embolism is defined as a systemic arterial embolism requiring the passage of a venous thrombus into the arterial circulatory system through a right-to-left shunt, and is commonly related to patent foramen ovale (PFO). However, coexisting pulmonary embolisms, deep vein thromboses (DVT), and multipe systemic arterial embolisms, associated with PFO, are rare. Here, we report a patient who had a cryptogenic ischemic stroke, associated with PFO, which is complicated with a massive pulmonary thromboembolism, DVT, and renal infarctions, and subsequently, the patient was treated using a thrombolytic therapy.

Coronary artery disease is the most important cause of mortality in patients with systemic lupus erythematous (SLE). After stenting for coronary artery disease in SLE patients similar to non-SLE patients, the risk of stent thrombosis is always present. Although there are reports of stent thrombosis in SLE patients, very late recurrent stent thrombosis is rare. We experienced a case of very late recurrent stent thrombosis (4 times) in a patient with SLE.

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