A Case in Which Stent Insertion is Considered to Have Triggered Contrast Medium-Induced Coronary Vasospasm

Abstract

he use of contrast medium has recently increased in various fields, including coronary angiography, but reports of induction of spasm in the coronary artery caused by contrast media are rare. [1][2][3][4][5][6] In the case reported here, a stent was placed for restenosis after percutaneous transluminal coronary angioplasty (PTCA) in a patient with no history of coronary vasospastic angina pectoris, but spasm appeared to be induced by the contrast medium Iomeprol. Case ReportA 75-year-old man was admitted to our hospital on July 24, 1996, with a diagnosis of unstable angina pectoris. Coronary risk factors included hypertension, diabetes mellitus, and a history of smoking. Emergency coronary angiography, performed on July 24, showed 75% stenosis in segment 7 of the left anterior descending coronary artery (LAD) and 90% stenosis in segment 13 of the left circumflex coronary artery (LCx). The right coronary artery (RCA) exhibited chronic complete occlusion in segment 2Japanese Circulation Journal Vol.63, April 1999 but received well-developed collaterals from the LAD. Three-vessel PTCA was performed at the patient's request. The LCx and the RCA were successfully dilated by plain old balloon angioplasty (POBA) alone. Because the PTCA balloon caused vascular dissection in the LAD, a PalmazSchatz stent (P-S stent) was inserted. Repeat angiography 8 months later revealed restenosis in the RCA, and a 3.0×20 mm Gianturco-Roubin II stent (GR-II stent) was inserted into the RCA from segment 1 to segment 2. Further followup angiography performed 7 months later showed subtotal occlusion at the same site; PTCA was repeated and the vessel was successfully dilated. However, upon follow-up angiography 3 months later, chest pain occurred with bradycardia and hypotension immediately after completion of left and right coronary angiography; ST elevation was noted in ECG leads II and III, and aVF. Repeat angiography showed complete occlusion of the RCA that we considered to be due to a spasm occurring proximal to the GR-II stent. No signs of allergy such as urticaria, conjunctivitis or facial edema were noted at this point. Spasm was resolved by administration of 1 mg of atropine sulfate, 0.5 mg of norepinephrine, and an intracoronary infusion of 15 mg of isosorbide dinitrate (ISDN). Although 75% stenosis according to the American Heart Association (AHA) scale remained at the site of stent insertion after resolution of the spasm, PTCA was performed again because subtotal occlusion had been observed previously; the lesion was diffuse, and the patient had strongly desired the procedure. Because balloon-induced vascular dissection was observed distal to the GR-II stent at this point, a P-S stent was inserted into Jpn Circ J 1999; 63: 315 -318 (Received November 12, 1998; revised manuscript received December 24, 1998; accepted December 25, 1998 A Gianturco-Roubin II (GR-II) stent was inserted in a 75-year-old man who developed restenosis of the right coronary artery (RCA) after percutaneous transluminal coronary angioplasty (PTCA). Al...

Dopamine‐1 Receptor Agonist: Renal Effects and Its Potential Role in the Management of Radiocontrast‐Induced Nephropathy

“…Interestingly, the incidence of hypotension was not significantly different than in the historic control group (fenoldopam = 3.8% vs control = 1.7%, P = ns ). Coronary interventions in this study included stent, Rotablator, Rota + stent, and AngioJet + stent, all of which are well known in carrying the risk of bradycardia and hypotension 35–41 . This study clearly documented the prophylactic effect of fenoldopam against radiocontrast‐induced nephropathy in patients with kidney disease both with and without diabetes.…”

“…Coronary interventions in this study included stent, Rotablator, Rota + stent, and AngioJet + stent, all of which are well known in carrying the risk of bradycardia and hypotension. [35][36][37][38][39][40][41] This study clearly documented the prophylactic effect of fenoldopam against radiocontrast-induced nephropathy in patients with kidney disease both with and without diabetes. Regretfully, the lack of randomization precludes definitive conclusion of fenoldopam's protective role against RIN.…”

“…A variety of factors have been implicated in mediating these hypotensive occurrences. [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] Mager et al 40 studied 180 consecutive patients who underwent uneventful percutaneous coronary balloon angioplasty and demonstrated a 14% incidence of at least 1 episode of symptomatic bradycardia and hypotension. In addition to angioplasty, Rotastenting and AngioJet procedures have also been highlighted as one of the factors responsible for hypotension.…”

“…41 During coronary interventions, coronary spasm, ischemia, left ventricular dysfunction, and endothelial damage can lead to neurohumoral activation, leading to intraprocedure and postprocedure vasomotor and hemodynamic effects. 36,38,40,[43][44][45] Furthermore, medications often administered during coronary intervention may also contribute to the hypotension. Midazolam, diazepam, diphenhydramine, fentanyl, and nitroglycerine (intracoronary, sublingual) all can produce hypotension.…”

The Incidence of Stent-edge Spasm After Stent Implantation in Patients With or Without Vasospastic Angina Pectoris

“…1,2) In addition several studies have reported that stent implantation is an option for the treatment of coronary vasospastic angina (VSA) that is resistant to adequate medical treatment. [3][4][5][6][7][8][9] On the other hand, Muroya, et al 10) reported that stent implantation can induce severe stent-edge spasm in patients without coronary spasm before stent implantation. In this situation, the following questions arise.…”