Can’t stand heavy metal: how to treat an ACS with severe metal allergy?

#CardioTwitterCase originally published on Twitter

This case was originally published on Twitter by @Costa_F_8

Case description

This is a 66-year-old female with a long-standing history of severe metal allergies, with severe cutaneous and respiratory symptoms after metal contact, with confirmed allergy to nickel, chromium, and cobalt and other metals.

The patient presented with progressive chest pain during the last week, which was ultimately present at rest. Physical examination and cardiac biomarkers supported a diagnosis of unstable angina, prompting urgent invasive assessment.

Coronary angiography revealed a significant lesion in the proximal left anterior descending artery (LAD). Optical coherence tomography (OCT) demonstrated intraplaque hemorrhage, raising concern for plaque instability and high thrombotic risk.

Given her documented hypersensitivity to multiple metals typically found in conventional stents, the therapeutic strategy required a device with minimal risk of allergic reaction. After discussion with the Heart Team, a decision was made to use a novel bioresorbable magnesium scaffold (Biotronik FreeSolve^TM), which offers both structural support and the advantage of complete resorption over time, thus avoiding prolonged exposure to allergenic metals.

The procedure began with careful wiring of the proximal LAD lesion using a workhorse guidewire. Predilatation was performed with a 3.0 mm noncompliant balloon under fluoroscopic guidance. Following optimal lesion preparation, a 3.5 × 18 mm bioresorbable magnesium scaffold was deployed, ensuring full expansion and coverage of the diseased segment. Postdilatation with a 3.5 noncompliant balloon confirmed adequate stent apposition. Repeat OCT imaging demonstrated appropriate scaffold expansion and strut distribution.

No intraprocedural complications occurred, and the patient remained hemodynamically stable throughout. She was discharged on dual antiplatelet therapy with aspirin and prasugrel, and advised to maintain close outpatient follow-up.

Media

Pre PCI OCT

Freesolve™ stent intervention

Post PCI OCT

Final remarks

This case underlines the importance of individualised stent selection in complex scenarios, particularly for patients with severe metal allergies. Among the options available, which included single vessel CABG and PCI with a drug-coated balloon, we preferred this novel interventional approach to provide a higher radial support and reduce recoil risk.