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Stent-Free Sirolimus DCB for Left Main STEMI: Acute and Long-Term OCT Follow-Up
Jayachandran Ravichandran1, Armando Tellez2, Erick Marlon Avila Gil3
1Cardiovascular Research Unit, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain.
Insights
Optical coherence tomography (OCT) identified plaque erosion in a left main (LM) ST-elevation myocardial infarction (STEMI) case, enabling a stent-free approach. This strategy led to successful vessel healing and avoided lifelong stenting risks.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Imaging
Background:
- Left main (LM) ST-elevation myocardial infarction (STEMI) traditionally requires urgent stent implantation.
- Intravascular imaging reveals plaque erosion as a potential alternative to stenting in LM STEMI.
Background:
Left main (LM) ST-elevation myocardial infarction (STEMI) is typically managed with urgent stent implantation according to current guidelines. Yet intravascular imaging has shown that plaque erosion may permit alternative strategies.
Case Summary:
A 43-year-old man with anterior STEMI and hypotension underwent angiography, revealing distal LM thrombus extending into the left anterior descending/left circumflex arteries. Postaspiration optical coherence tomography (OCT) confirmed plaque erosion without rupture. Following lesion preparation, a drug-coated balloon-only strategy was applied to all 3 vessels. Follow-ups at 20 days and 15 months confirmed vessel patency, satisfactory healing, and no recoil or neoatherosclerosis.
Discussion:
Current guidelines lack support for stent-free LM STEMI intervention. However, OCT-guided management allows for individualized treatment in young patients by characterizing lesion biology. Long-term follow-up demonstrates successful vessel healing, suggesting that avoiding permanent metallic scaffolds in selected cases may mitigate lifelong stenting risks.
Take-Home-Message:
OCT can identify plaque erosion and guide stent-free percutaneous coronary intervention in select left main STEMI cases, offering durable healing and flexibility in antithrombotic therapy.
