Acute stent thrombosis in a sirolimus eluting stent after wasp sting causing acute myocardial infarction: a case report. Cases J. 2009;2:780. [PMID: 19918484 PMCID: PMC2769374 DOI: 10.4076/1757-1626-2-7800]

Angina and Arrhythmia Symptoms Following Multiple Bee Stings: Kounis Syndrome

Kounis syndrome (KS) is an acute coronary syndrome including coronary spasm, acute myocardial infarction, and stent thrombosis preceded by an anaphylactic, anaphylactoid, allergic, or hypersensitivity injury. In this case presentation, we discussed Type I and Type II KS. Case 1 was a 72-y-old man who presented to the emergency department with allergic symptoms and chest pain that developed after multiple bee stings. Electrocardiography showed ST depression in the lateral leads. Case 2 was a 42-y-old woman who presented to the emergency department with complaints of chest pain, dizziness, and presyncope that developed after multiple bee stings. Mobitz Type II Block with right bundle branch block was observed in 42 beats·min-1 in the electrocardiography. Both patients were first treated for allergic reaction. Although early percutaneous coronary intervention was performed for graft thrombosis in Case 1, a permanent pacemaker was inserted in Case 2. The patients were discharged without any complications. Increasing physician awareness towards the existence of KS can prevent fatal outcomes with early diagnosis and treatment.

Acute coronary artery stent thrombosis caused by a spasm: A case report

BACKGROUND

Acute stent thrombosis (AST) is a serious complication of percutaneous coronary intervention (PCI). The causes of AST include the use of stents of inappropriate diameters, multiple overlapping stents, or excessively long stents; incomplete stent expansion; poor stent adhesion; incomplete coverage of dissection; formation of thrombosis or intramural hematomas; vascular injury secondary to intraoperative mechanical manipulation; insufficient dose administration of postoperative antiplatelet medications; and resistance to antiplatelet drugs. Cases of AST secondary to coronary artery spasms are rare, with only a few reports in the literature.

CASE SUMMARY

A 55-year-old man was admitted to the hospital with a chief complaint of back pain for 2 d. He was diagnosed with coronary heart disease and acute myocardial infarction (AMI) based on electrocardiography results and creatinine kinase myocardial band, troponin I, and troponin T levels. A 2.5 mm × 33.0 mm drug-eluting stent was inserted into the occluded portion of the right coronary artery. Aspirin, clopidogrel, and atorvastatin were started. Six days later, the patient developed AST after taking a bath in the morning. Repeat coronary angiography showed occlusion of the proximal stent, and intravascular ultrasound showed severe coronary artery spasms. The patient’s AST was thought to be caused by coronary artery spasms and treated with percutaneous transluminal coronary angioplasty. Postoperatively, he was administered diltiazem to inhibit coronary artery spasms and prevent future episodes of AST. He survived and reported no discomfort at the 2-mo follow-up after the operation and initiation of drug treatment.

CONCLUSION

Coronary spasms can cause both AMI and AST. For patients who exhibit coronary spasms during PCI, diltiazem administration could reduce spasms and prevent future AST.

Brachial Artery Thrombosis following Multiple Wasp Bites

Wasp bites can give rise to multiple clinical manifestations ranging from local reactions to multisystem involvement. Stroke and myocardial infarctions following wasp envenomation are reported in the literature. We describe a rare case of brachial artery thrombosis following multiple wasp bites.

Mobitz Type-2 Heart Block After a Bee-Sting

We report the case of a patient who developed symptomatic bradycardia and Mobitz type 2 heart block one week after a single bee sting. This required implantation of a permanent pacemaker. The patient had no significant past medical history, and previous electrocardiogram (ECGs) did not show heart block or bradycardia. He has been physically active in the past and denied any such symptoms. We presume bee sting to be the cause of his symptomatic bradycardia and heart block. We also think that his heart block was reversible and has since resolved, as his most recent device check showed minimal V-pacing. The cause of his heart block can be either Kounis syndrome or Apamin-mediated calcium channel block. A detailed discussion is done separately.

Kounis Syndrome after Angioplasty of the Superficial Femoral Artery with Paclitaxel-Coated Balloon

Drug-coated balloons are used widely as a form of endovascular treatment for peripheral arterial disease, to improve patency by reducing neointimal hyperplasia and restenosis. We present a rare case of acute coronary syndrome secondary to anaphylaxis after inflation of a paclitaxel-coated balloon used to treat a recurrent superficial femoral artery stenosis.

Thrombotic responses to coronary stents, bioresorbable scaffolds and the Kounis hypersensitivity-associated acute thrombotic syndrome

Percutaneous transluminal coronary angioplasty with coronary stent implantation is a life-saving medical procedure that has become, nowadays, the most frequent performed therapeutic procedure in medicine. Plain balloon angioplasty, bare metal stents, first and second generation drug-eluting stents, bioresorbable and bioabsorbable scaffolds have offered diachronically a great advance against coronary artery disease and have enriched our medical armamentarium. Stented areas constitute vulnerable sites for endothelial damage, endothelial dysfunction, flow turbulence, hemorheologic changes, platelet dysfunction, coagulation changes and fibrinolytic disturbances. Implant surface attracts several proteins such as albumin, fibronectin, fibrinogen, and complement that lead to complement system activation. Macrophages recognize the implant as foreign substance due to protein adsorption and its continuous presence results in macrophage differentiation and fusion into foreign body giant cells. Polymer coating, stent metallic platforms and the released drugs can act as strong antigenic complex that apply continuous, repetitive, persistent and chronic hypersensitivity irritation to the coronary intima. The concomitant administration of oral antiplatelet drugs and environmental exposures can induce hypersensitivity inflammation. A class of platelets, activated via high-affinity and low-affinity IgE hypersensitivity receptors FCγRI, FCγRII, FCεRI and FCεRII, can induce Kounis hypersensitivity-associated thrombotic syndrome inside the stented coronaries. Type III variant of this syndrome is diagnosed when coronary artery stent thrombosis is associated with thrombus infiltrated by eosinophils or mast cells and/or when coronary intima, media and adventitia adjacent to stent, is infiltrated by eosinophils or mast cells. Careful history of hypersensitivity reactions to all implanted materials and concomitant drugs with monitoring of inflammatory mediators as well as lymphocyte transformation studies to detect hypersensitivity must be undertaken in order to avoid disastrous consequences. Food and Drug Administration recommendations for coronary stent implantation should be applied also to bioresorbable scaffolds. Further studies with inert and non-allergenic implants are necessary.

Early stent thrombosis secondary to food allergic reaction: Kounis syndrome following rice pudding ingestion

Kounis syndrome is the concurrence of coronary spasm, acute myocardial infarction or stent thrombosis, with allergic reactions in the setting of mast-cell and platelet activation. In this report Kounis syndrome manifesting as stent thrombosis with left ventricular thrombus formation was triggered by a food-induced allergic reaction. The allergic reaction to food was confirmed by oral rice pudding ingredients challenge test while skin tests were inconclusive. To our knowledge, this is first report of early stent thrombosis secondary to food allergic reaction in a 70-year-old man patient who was found to have left ventricular thrombus and undiagnosed hypertrophic cardiomyopathy.

Anaphylactic Shock: Kounis Hypersensitivity-Associated Syndrome Seems to be the Primary Cause

Experiments have shown that anaphylaxis decreases cardiac output; increases left ventricular end diastolic pressure; induces severe early acute increase in respiratory resistance with pulmonary interstitial edema; and decreases splanchnic, cerebral, and myocardial blood flow more than what would be expected from severe arterial dilation and hypotension. This is attributed to the constrictive action of inflammatory mediators released during anaphylactic shock. Inflammatory mediators such as histamine, neutral proteases, arachidonic acid products, platelet-activating factor (PAF), and a variety of cytokines and chemokines constitute the pathophysiologic basis of Kounis hypersensitivity-associated acute coronary syndrome. Although the mechanisms of anaphylactic shock still remain to be elucidated, myocardial involvement due to vasospasm-induced coronary blood flow reduction manifesting as Kounis syndrome should be always considered. Searching current experimental and clinical literature on anaphylactic shock pathophysiology, causality, clinical appearance, and treatment via PubMed showed that differentiating global hypoperfusion from primary tissue suppression due to mast cell mediator constrictive action on systemic arterial vasculature is a challenging procedure. Combined tissue suppression from arterial involvement and peripheral vasodilatation, perhaps, occur simultaneously. In cases of anaphylactic shock treatment targeting the primary cause of anaphylaxis together with protection of coronary vasculature and subsequently the cardiac tissue seems to be of paramount importance.

Stent hypersensitivity and infection in sinus cavities

Persistent mucosal inflammation, granulation tissue formation, hypersensitivity, and multifactorial infection are newly described complications of retained drug-eluting stents from endoscopic sinus surgery for refractory rhinosinusitis. In an important report published in Allergy and Rhinology, a 45-year-old male patient suffering from recalcitrant chronic rhinosinusitis underwent functional endoscopic sinus surgery and was found, for the first time, to have steroid-eluting catheters that were inadvertently left in the ethmoid and frontal sinuses. The retained catheters had caused persistent mucosal inflammation and formation of granulation tissue denoting hypersensitivity reaction. These consequences had induced perpetuation of symptoms of chronic rhinosinusitis. Meticulous removal of the retained stents with the nitinol wings from inflamed tissues of the frontal, ethmoidal, and sphenoethmoidal recesses in which they were completely imbedded was successfully performed without polypoid regrowth. Cultures of specimens taken from both left and right stents showed heavy growth of Stenotrophomonas maltophilia and moderate growth of Klebsiella oxytoca, coagulase negative Staphylococcus, and beta-hemolytic Streptococcus anginosus. Fungal infection was not detected. The current knowledge and experience regarding stent hypersensitivity and infection in relation with the use of stents in sinus cavities is reviewed.

Kounis syndrome presenting as very late stent thrombosis in an everolimus-eluting stent following wasp stings

Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation following an allergic insult. We report a 56-year-old man who experienced a ST-segment elevation myocardial infarction after wasp stings. The patient presented without signs of anaphylaxis or shock. Coronary angiography showed an everolimus-eluting stent thrombosis (ST) of the left anterior descending artery occluding the vessel completely which was deployed for stable angina 3 years ago. The patient had been compliant with anti-platelet therapy, and no relevant cardiovascular events occurred until the day of admission. We interpreted our patient's condition as a manifestation of Kounis syndrome. To our knowledge, this is the first case of Kounis syndrome showing very late ST in a second-generation drug-eluting stent caused by wasp stings.

The bee sting related wolff-Parkinson-white syndrome

Hymenoptera stings are common reasons for emergency visits. The admissions for the hymenoptera stings occur for systemic or unusual reactions. We are reporting a man with multiple bee stings, who presented with dizziness and palpitations and was found to have ECG findings of the Wolff-Parkinson-White syndrome. He had no worsening of symptoms or new ECG changes during his hospitalization. The hymenoptera related cardiac effects have also been reviewed and summarized.

Kounis syndrome: a new twist on an old disease

Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation, such as allergies or hypersensitivity and anaphylactic or anaphylactoid insults that can involve other interrelated and interacting inflammatory cells behaving as a 'ball of thread'. It is caused by inflammatory mediators such as neutral proteases including tryptase and chymase, arachidonic acid products, histamine, platelet activating factor and a variety of cytokines and chemokines released during the activation process. Platelets with FCεRI and FCεRII receptors also participate in the above cascade. Vasospastic allergic angina, allergic myocardial infarction and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells constitute the three reported variants of this syndrome. Kounis syndrome is a ubiquitus disease that represents a magnificent natural paradigm and nature's own experiment, in a final trigger pathway implicated in cases of coronary artery spasm and plaque rupture. Kounis syndrome can complicate anesthesia, vaccination, medical therapy and stent implantation and it seems to be associated with coronary allograft vasculopathy and takotsubo syndrome, it can often be confused with hypersensitivity myocarditis and can be the cause of unexplained sudden death. Kounis syndrome has revealed that the same mediators released from the same inflammatory cells are present in acute coronary events of nonallergic etiology. These cells are not only present in the culprit region before plaque erosion or rupture but they release their contents just before an actual coronary event. Therefore, does Kounis syndrome represent a magnificent natural paradigm and nature's own experiment in a final trigger pathway implicated in cases of coronary artery spasm and plaque rupture showing a novel way towards our effort to prevent acute coronary syndromes? Drugs, substances targeting the stem cell factor that is essential for mast cell development, proliferation, survival, adhesion and homing as well as monoclonal antibodies and natural molecules that protect mast cell surface and stabilize mast cell membrane could emerge as novel therapeutic ways capable to prevent acute coronary and acute cerebrovascular events.

Eosinophilic responses to stent implantation and the risk of Kounis hypersensitivity associated coronary syndrome

The use of drug eluting stents constitutes a major breakthrough in current interventional cardiology because it is more than halves the need of repeat interventions. It is incontrovertible that coronary stents, in general, have been beneficial for the vast majority of patients. A small increase in thrombosis, following DES implantation, is offset by a diminished risk of complications associated with repeat vascularization. However, late and, especially, very late stent thrombosis is a much feared complication because it is associated with myocardial infarction with increased mortality. Despite that stent thrombosis is thought to be multifactorial, so far clinical reports and reported pathology findings in patients died from coronary stent thrombosis as well as animal studies and experiments, point toward a hypersensitivity inflammation. The stented and thrombotic areas are infiltrated by interacting, via bidirectional stimuli inflammatory cells including eosinophils, macrophages, T-cells and mast cells. Stented regions constitute an ideal surrounding for endothelial damage and dysfunction, together with hemorheologic changes and turbulence as well as platelet dysfunction, coagulation and fibrinolytic disturbances. Drug eluting stent components include the metal strut which contains nickel, chromium, manganese, titanium, molybdenum, the polymer coating and the impregnated drugs which for the first generation stents are: the antimicrotubule antineoplastic agent paclitaxel and the anti-inflammatory, immunosuppressive and antiproliferative agent sirolimus. The newer stents which are called cobalt-chromiun stents and elute the sirolimus analogs everolimus and zotarolimus both contain nickel and other metals. All these components constitute an antigenic complex inside the coronary arteries which apply chronic, continuous, repetitive and persistent inflammatory action capable to induced Kounis syndrome and stent thrombosis. Allergic inflammation goes through three phases, the early phase, the late phase and the chronic phase and these three phases correspond temporally with early (acute and sub acute), late and very late stent thrombosis. Bioabsorbable allergy free poly lactic acid self expanding stents, nickel free stainless steel materials, stent coverage with nitric oxide donors and antibodies with endothelial progenitor cell capturing abilities as well as stents eluting anti-inflammatory and anti-allergic agents might be the solution of this so feared and devastating stent complication.

Therapeutic potential for protein kinase C inhibitor in vascular restenosis

Vascular restenosis, an overreaction of biological response to injury, is initialized by thrombosis and inflammation. This response is characterized by increased smooth muscle cell migration and proliferation. Available pharmacological treatments include anticoagulants, antiplatelet agents, immunosuppressants, and antiproliferation agents. Protein kinase C (PKC), a large family of serine/threonine kinases, has been shown to participate in various pathological stages of restenosis. Consequently, PKC inhibitors are expected to exert a wide range of pharmacological activities therapeutically beneficial for restenosis. In this review, the roles of PKC isozymes in platelets, leukocytes, endothelial cells, and smooth muscle cells are discussed, with emphasis given to smooth muscle cells. We will describe cellular and animal studies assessing prevention of restenosis with PKC inhibitors, particularly targeting -α, -β, -δ, and -ζ isozymes. The delivery strategy, efficacy, and safety of such PKC regulators will also be discussed.