Kounis syndrome type III triggered by stents in patients with coronary artery disease: A review of clinical cases

Table 1 Characteristics of patients described in the selected case reports and clinical features of myocardial infarction

Parameter	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6
Ref.	Miura et al[20], 2021	Almpanis et al[21], 2010	Boucher et al[22], 2022	Giraldo-Tugores et al[23], 2023	Hoshi et al[24], 2014	Fujisaki et al[25], 2020
Age (years)/sex	69/female	59/male	85/male	52/male	65/female	67/male
Allergy history	Allergic reactions to unidentified metals (30 years prior)	Bronchial asthma, nasal polyposis, hay fever, NSAID allergy	“Swelling” with penicillin	Childhood contact with vanadium-chromium auto tools (asymptomatic)	Not contributory	Not contributory
Case features	Recurrent stent thrombosis within 1 hour of implantation	NA	Multiple revascularizations (4 stents)	Recurrent in-stent restenosis; multiple revascularizations (7 stents)	Very late stent thrombosis	Very late stent thrombosis
Allergens	Nickel, cobalt	Nickel, chromium, polymer coating	Nickel, manganese, titanium, vanadium, zinc	Vanadium	Nickel, cobalt	Sirolimus
Allergic reaction in KS	None	None	Diffuse pruritic maculopapular rash with eosinophilia (day 74)	None	None	Recurrent generalized urticaria 14 years post-stenting
Stent type	Zotarolimus-eluting stent (Resolute Onyx); everolimus-eluting stent (XIENCE Sierra)	SES (CYPHER)	Zotarolimus-eluting stent (Resolute DP-DES)	Zotarolimus-eluting stent (Onyx)	SES (CYPHER)	SES
Time to thrombosis/restenosis	1 hour	2 hours	43 days	6 months	36 months	14 years
ECG findings	ST elevation in II, III, aVF	ST elevation in II, III, aVF	NSTEMI	NA	STEMI	ST elevation in V1-V5
CAG findings	Thrombosis in proximal LAD; subtotal thrombotic occlusion in 4th branch of PDA (TIMI 1-2)	RCA stent thrombosis	RCA stent thrombosis and aneurysm in proximal segment	Severe restenosis in LAD and later in LCx	Acute thrombotic stent occlusion; aneurysms at stent edges	LAD stent thrombosis; peri-stent contrast staining at 3 months
Complications	Recurrent stent thrombosis	Cardiogenic shock, ventricular flutter, atrial flutter, acute LV failure	RCA aneurysm	Neointimal changes, neoatherosclerosis	Coronary aneurysms at stent edges; stent malapposition; neoatherosclerosis	Coronary evaginations
Confirmation method	CAG, IVUS, OCT; patch test (nickel/cobalt); thrombus histology (eosinophils, no mast cells); CYP2C19 genotyping	CAG	CAG; skin tests (day 454): Metal sensitivity; blood eosinophilia (2500/μL, reference: 100-300/μL)	CAG; patch and lymphocyte transformation tests (vanadium); SEM of Onyx (vanadium 0.1%); OCT: Neointimal hyperplasia	CAG, OCT: Residual thrombus, malapposition, 8 mm aneurysm; IVUS; angioscopy; histology: Eosinophils and neutrophils (HE)	CAG; OCT: Evaginations
Histopathological confirmation	Yes	No	No	No	Yes	No
Diagnosis status	Confirmed	Suspected	Suspected	Suspected	Confirmed	Suspected
Treatment	IV hydrocortisone 125 mg, oxygen, saline; aspiration thrombectomy and balloon angioplasty; IABP; switch from clopidogrel to prasugrel	Coronary angioplasty, cardioversion (300 J), dopamine, dobutamine, fluids, diuretics, oxygen, amiodarone	Manual thrombectomy, balloon angioplasty; DAPT modified with addition of prednisolone 30 mg/day; fatal outcome	CABG × 2; stent-free strategy	Aspiration thrombectomy, balloon angioplasty	Thrombectomy, angioplasty, catheter thrombolysis (urokinase); lifelong DAPT; no steroids or antihistamines (patient declined)
Outcome	Favorable; discharged day 12; asymptomatic at 3 months	Favorable; discharged day 14; asymptomatic at 1 year	Death after 3 years	Favorable	Favorable	Favorable; discharged day 14; no recurrence at 1 year

NSAID: Nonsteroidal anti-inflammatory drugs; CAG: Coronary angiography; CABG: Coronary artery bypass grafting; OCT: Optical coherence tomography; IVUS: Intravascular ultrasound; STEMI: ST-elevation myocardial infarction; NSTEMI: Non–ST-elevation myocardial infarction; IABP: Intra-aortic balloon pump; DAPT: Dual antiplatelet therapy; CYP2C19: Cytochrome P450 family 2 subfamily C member 1; TIMI: Thrombolysis in myocardial infarction; ECG: Electrocardiogram; HE: Hematoxylin and eosin; IV: Intravenous; KS: Kounis syndrome; LAD: Left anterior descending; LCx: Left circumflex artery; LV: Left ventricle; NA: Not available; PDA: Posterior descending artery; RCA: Right coronary artery; SEM: Scanning electron microscopy; SES: Sirolimus-eluting stent.