Letter to the Editor
Kounis syndrome and simultaneous multivessel acute coronary syndromes after successful drug-eluting stent implantation

https://doi.org/10.1016/j.ijcard.2007.04.032Get rights and content

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Summary

Recent reports have shown that implantation of drug-eluting stents (DES) may be associated with simultaneous, multivessel, repeated, remote and peripheral arterial thrombosis. Clinical and pathology findings point towards a possible hypersensitivity reaction to DES manifesting as Kounis syndrome. Prophylactic and therapeutic measures should be undertaken in order to avoid this dangerous complication.

Simultaneous multivessel drug-eluting stent thrombosis

In the very interesting report published in the this Journal [1] the authors reported on a patient with cardiogenic shock complicated by acute myocardial infarction due to simultaneous subacute coronary thrombosis occurring 3 days after implantation of two sirolimus stents in the proximal descending coronary artery and in the proximal right coronary artery. Although the they did not comment on the possible etiology of this association, they concluded that the use of multiple drug-eluting stents

DES thrombosis: A much feared stent complication

Thrombosis following successful drug-eluting stent (DES) implantation is a feared complication which may lead to catastrophic consequences including myocardial infarction with estimated 30-day mortality ranging from 20–48% [10]. Stent thrombosis has been classified as acute, occurring within 48 hours, subacute, occurring between the 2nd and the 30th day, late, occurring after the first 30 days to 1 year and very late occurring after 1 year of the implantation. The development of stent

Simultaneous multivessel vasoconstriction following implantation of DES

Abnormal vasomotion with vasoconstriction has been reported in patients with DES during exercise 6 months after implantation [15]. In this study, patients with bare metal stent implantation preserved normal vasomotion with vasodilatation. Severe, diffuse multivessel coronary spasm has been reported in a recent report [16]. Among 13 patients who had implanted DES, 5 developed severe, diffuse and simultaneous spasm involving multiple coronary vessels. Two of them died. Post mortem in one of these

Repeated, remote and combined stent thrombosis

Acute repeated DES thrombosis has been described in a young woman with severe stenosis of the proximal left anterior descending coronary artery [18]. She presented with acute myocardial infarction and total occlusion of the stent 1 year after stenting while she had discontinued the antiplatelet treatment. She took aspirin and ticlopidin for 9 months thereafter. Two months later, she presented with acute myocardial infarction with re-occlusion at the stent. Blood examination showed no manifest

Conclusions

These reports show that DES thrombosis might represent not a local phenomenon but a more general hypersensitivity event involving circulating inflammatory mediators able to induce thrombotic events and/or vasoconstriction as in both variants of Kounis syndrome [21]. Local release of inflammatory mediators seems to elicit a systemic response culminating in mast cell activation [22]. Therefore, in a effort to prevent ant treat these disastrous consequences we recommend, especially for atopic

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  • Cited by (19)

    • Kounis syndrome

      2012, Medicina Intensiva
    • Kounis syndrome in a patient with ovarian cancer and allergy to iodinated contrast media: Report of a case: Vasospastic angina induced by chemotherapy

      2011, International Journal of Cardiology
      Citation Excerpt :

      This topic is an important one since patients affected by ischemic heart disease receiving stent implantation can be prone to hypersensitivity reactions from five potential antigens, namely nickel strut, polymer coating, eluted drug, clopidogrel and aspirin [10]. Some hypersensitivity cases have indeed been associated with implantation of drug eluting coronary stents [11–13] and between them a case of intra-stent thrombosis in a subject with allergy to larvae of fly carvaria [14]. On the other hand Kounis syndrome has also been associated with tako-tsubo syndrome [15,16] and with many other anecdotical clinical conditions such as viper bite or hymenoptera sting [17–20], administration of some drugs like penicillin [4,21], amoxicillin [22], diclofenac sodium [23], rocuronium [24], mesalamine [25], proton pump inhibitors like lansoprazole [26], and even aspirin [27].

    • Acute stent thrombosis and atopy: Implications for Kounis syndrome

      2010, International Journal of Cardiology
      Citation Excerpt :

      Patients undergoing stent implantation receive several substances, which have antigenic properties. These substances include the metal stent, which is made from 316 L stainless steel containing nickel, chromium, manganese, titanium and molybdenum, and drug eluting devices include the polymer coating and the impregnated drugs which for today are the antimicrotubule, antineoplastic agent paclitaxel, the anti-inflammatory, immunosuppressive and antiproliferative agent rapamycin [2]. The much feared intrastent thrombosis is regarded as multifactorial process but so far there is much clinical, experimental and laboratory evidence that hypersensitivity involving eosinophils, mast cells, T-lymphocytes and macrophages play an important role [3].

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