Anterior AMI with an unusual angiographic image

A 53-year-old male smoker with hypertension and a family history of dyslipidemia and early ischemic heart disease in family members was diagnosed with anterior ST-segment elevation acute coronary syndrome (STEACS) in 2017. He was treated with a 4 mm × 18 mm everolimus-eluting stent implanted in the proximal left anterior descending coronary artery and 2 overlapping distal stents. The procedure was uneventful, and the remaining arteries showed ectasia with diffuse atheromatous disease. An echocardiogram revealed the presence of mild left ventricular systolic dysfunction. The patient was readmitted after experiencing a new anterior STEACS due to very late thrombosis of the previous stent in the proximal left anterior descending coronary artery, where an external calcified image was found around the stent (figure 1A,B: arrows). The study was completed with optical coherence tomography (figure 2A,B), which revealed the presence of abundant thrombotic content, and stent malapposition, without visualization of the surrounding arterial wall, indicating a large thrombosed and calcified aneurysm. Thrombus aspiration and a drug-coated balloon were used, along with glycoprotein IIb-IIIa inhibitors, resulting in final TIMI grade 3 flow. Computed tomography (figure 3: arrows) performed during admission confirmed the presence of a 24 mm coronary aneurysm with...