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A 62-year-old man presented with severe pancreatitis and developed ventricular tachycardia requiring cardioversion. His ECG revealed a new right bundle branch block with anterior ST-segment elevation. The patient was referred for primary percutaneous coronary intervention. Angiography revealed proximal occlusion of the left anterior descending (LAD) artery. Thrombectomy liberated moderate thrombus, eptifibatide was administered, and two bare metal stents were placed in the LAD. The patient was then transferred to the coronary care unit and eptifibatide was continued. One hour later, he became hypotensive, bradycardic, developed asystole that was non-responsive to therapy, and died. Acute stent thrombosis was suspected and autopsy was performed.
The coronary arteries were perfused with bismuth-gelatin (#), the LAD was removed en-block, and microcomputed tomography (microCT) was performed. Three-dimensional and tomographic microCT images (Panels A and C) revealed a non-occlusive filling defect limited to the stented segment of the LAD with patent branch vessels (see Supplementary material online, Videos 1 and 2). Histopathological correlation (Panel D) showed a ruptured plaque with a large necrotic core (NC) in the stented proximal LAD (Panels E and F). There was persistent luminal thrombus (Thr) narrowing the residual lumen corroborating the microCT findings. Post-mortem clot (*) is noted adjacent to the thrombus. The remainder of the heart was sectioned revealing a large haemorrhagic anterior infarction (Panel B) without mechanical disruption; incidentally, residual-dependent bismuth overflow was noted.
Despite aspiration, eptifibatide, and stent placement, a significant amount of thrombus remained lining the stented vessel encroaching on the lumen. MicroCT and histology are complementary in the post-mortem evaluation of stented arterial segments.
Funding to pay the Open Access publication charges for this article was provided by Section of Cardiology, Dartmouth-Hitchcock Medical Center.