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Intravascular ultrasound supported percutaneous coronary intervention of a large diameter right coronary artery
IHJ Cardiovascular Case Reports (CVCR) 2 (2018) 106–107
Contents lists available at ScienceDirect
IHJ Cardiovascular Case Reports (CVCR) journal homepage: www.elsevier.com/locate/ihjccr
Intravascular ultrasound supported percutaneous coronary intervention of a large diameter right coronary artery Rajesh Vijayvergiya ∗ , Ankush Gupta, Ganesh Kasinadhuni, Darshan Krishnappa, Prashant Panda Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Sector 12, Chandigarh, 160012, India
a r t i c l e
i n f o
Article history: Received 23 October 2017 Received in revised form 3 January 2018 Accepted 10 February 2018
a b s t r a c t This is an unusual case of very large diameter right coronary artery, where a 6 mm peripheral bare metal stent was deployed and intravascular ultrasound was done to have optimal end results. Importance of appropriate size stent is discussed, which will be of interest to readers. © 2018 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A 54-years-old chronic smoker male presented with rest angina of 2-days duration. Electrocardiogram showed ST depression, T inversion in inferior leads. Echocardiogram showed no regional wall motion abnormality with left ventricular ejection fraction of 60%. Coronary angiography revealed an 80% discrete distal right coronary artery (RCA) stenosis on quantitative coronary angiography (QCA) estimation (Fig. 1A). Left coronary artery was normal. An intra-vascular ultrasound (IVUS) of distal RCA revealed 6.00 mm proximal reference vessel diameter (RVD), 28.3 mm2 reference vessel area (RVA), 2.00 mm minimal luminal diameter (MLD), 4.08 mm2 minimal luminal area (MLA), 76% diameter stenosis (DS) of a 10 mm long lesion having a fibro-calcific plaque burden of 76% (Fig. 1D, Video 1). There was no ulcerated plaque or thrombus at the site of lesion. (Video 1). There was no significant remodeling distal or proximal to the site of lesion. A 6 × 20 mm balloon-expandable bare metal stent (Hippocampus renal stent, 65-m strut thickness, Medtronic Inc, Minneapolis, Minnesota, US) was deployed at 14atms (Fig. 1B). A repeat IVUS run showed 25% residual DS, MLD of 4.53 mm with MLA of 16.15 mm2 (Fig. 1E). The stented segment was post-dilated with 6 × 20 mm peripheral balloon (Submarine Rapido PTA balloon, Medtronic Inc.) at 17 atms. There was TIMI-3 flow in RCA with no residual stenosis (Fig. 1C). A repeat IVUS run showed MLD of 5.19 mm, MLA of 18.05 mm2 and a well apposed stent struts (Fig. 1F, Video 2). Patient was discharged on dual antiplatelet therapy on following day and was asymptomatic at 1- year of follow-up.
There is a technical challenge in performing percutaneous coronary intervention (PCI) of a large diameter coronary artery of >5 mm dimension because of non-availability of appropriate sized coronary stent and balloon. The maximum diameter of presently available coronary stents is of 5 mm (Taxus stent, Boston Scientific Co., Natick, MA, US; and Resolute Onyx, Medtronic Inc.). In such situation, operator has to either oversized the stent with appropriate sized balloon or performs simultaneous kissing balloon dilatation or stenting. An undersized or unexpanded stent has a risk of stent thrombosis and instent re-stenosis,1–3 while oversizing of a stent may result into polymer fracture, stent deformation and impaired local drug kinetics.4–5 Therefore, a thin strut coronary stent of >5 mm size is a necessity during PCI of such a large diameter coronaries, which is presently not available in the market. A selfexpanding stent like STENTYS can be an alternative option in such situations.6 A peripheral bare metal stent implantation in coronaries is an off-label use; the safety and efficacy of which should be extrapolated with caution. Author (RV) had personal experience of 3-such patients in the past, in whom a peripheral bare metal stent of >5 mm size was implanted and all had favorable long term clinical outcome. In such situation, intra-vascular imaging helps in PCI optimization, while visual or QCA estimated lesion assessment can be fallacious. In conclusion, the index case had demonstrated a successful IVUS supported PCI of a large RCA lesion of 6 mm dimension, by using a balloon-expandable peripheral bare metal stent.
∗ Corresponding author. E-mail address: [email protected] (R. Vijayvergiya). https://doi.org/10.1016/j.ihjccr.2018.02.004 2468-600X/© 2018 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
R. Vijayvergiya et al. / IHJ Cardiovascular Case Reports (CVCR) 2 (2018) 106–107
107
Fig. 1. Percutaneous coronary intervention details of distal right coronary artery (RCA) lesion. A. Coronary angiogram showing discrete 80% stenosis of distal RCA. B. Coronary angiogram following a 6 × 20 mm stent deployment, showing residual stenosis. C. Coronary angiogram following post- dilatation with 6 mm balloon, showing TIMI-3 flow with no residual stenosis. D. Intravascular ultrasound finding corresponding to figure A, showing 76% diameter stenosis (S) of distal RCA. E. Intravascular ultrasound finding corresponding to figure B, showing 25% residual diameter stenosis. F. Intravascular ultrasound finding corresponding to figure C, showing 5.19 mm minimal luminal diameter, 18.05 mm2 minimal luminal area, and well apposed stent struts. Abbreviations: DS-diameter stenosis; MLA-minimal luminal area; MLD-minimal luminal diameter; RVA-reference vessel area; RVD-reference vessel diameter.
Conflict of interest We have no conflict of interest. Acknowledgment There is no funding from any agency or institution was taken for this manuscript. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.ihjccr.2018.02.004. References 1. Uren NG, Schwarzacher SP, Metz JA, et al. POST Registry Investigators: Predictors and outcomes of stent thrombosis: an intravascular ultrasound registry. Eur Heart J. 2002;23:124–132.
2. Fujii K, Carlier SG, Mintz GS, et al. Stent underexpansion and residual reference segment stenosis are related to stent thrombosis after sirolimus-eluting stent implantation: an intravascular ultrasound study. J Am Coll Cardiol. 2005;45:995–998. 3. Bertrand OF, De Larochellière R, Joyal M, Bonan R, Mongrain R, Tardif JC. Incidence of stent under-deployment as a cause of in-stent restenosis in long stents. Int J Cardiovasc Imaging. 2004;20:279–284. 4. Guérin P, Pilet P, Finet G, et al. Drug-eluting stents in bifurcations: bench study of strut deformation and coating lesions. Circ Cardiovasc Interv. 2010;3:120–126. 5. Ng J, Foin N, Ang HY, et al. Over-expansion capacity and stent design model: An update with contemporary DES platforms. Int J Cardiol. 2016;221:171–179. 6. Lu H, I.Jsselmuiden AJ, Grundeken MJ, et al. First-in-man evaluation of the novel balloon delivery system STENTYS Xposition S for the self-apposing coronary artery stent: impact on longitudinal geographic miss during stenting. EuroIntervention. 2016;11:1341–1345.
Contents lists available at ScienceDirect
IHJ Cardiovascular Case Reports (CVCR) journal homepage: www.elsevier.com/locate/ihjccr
Intravascular ultrasound supported percutaneous coronary intervention of a large diameter right coronary artery Rajesh Vijayvergiya ∗ , Ankush Gupta, Ganesh Kasinadhuni, Darshan Krishnappa, Prashant Panda Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Sector 12, Chandigarh, 160012, India
a r t i c l e
i n f o
Article history: Received 23 October 2017 Received in revised form 3 January 2018 Accepted 10 February 2018
a b s t r a c t This is an unusual case of very large diameter right coronary artery, where a 6 mm peripheral bare metal stent was deployed and intravascular ultrasound was done to have optimal end results. Importance of appropriate size stent is discussed, which will be of interest to readers. © 2018 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A 54-years-old chronic smoker male presented with rest angina of 2-days duration. Electrocardiogram showed ST depression, T inversion in inferior leads. Echocardiogram showed no regional wall motion abnormality with left ventricular ejection fraction of 60%. Coronary angiography revealed an 80% discrete distal right coronary artery (RCA) stenosis on quantitative coronary angiography (QCA) estimation (Fig. 1A). Left coronary artery was normal. An intra-vascular ultrasound (IVUS) of distal RCA revealed 6.00 mm proximal reference vessel diameter (RVD), 28.3 mm2 reference vessel area (RVA), 2.00 mm minimal luminal diameter (MLD), 4.08 mm2 minimal luminal area (MLA), 76% diameter stenosis (DS) of a 10 mm long lesion having a fibro-calcific plaque burden of 76% (Fig. 1D, Video 1). There was no ulcerated plaque or thrombus at the site of lesion. (Video 1). There was no significant remodeling distal or proximal to the site of lesion. A 6 × 20 mm balloon-expandable bare metal stent (Hippocampus renal stent, 65-m strut thickness, Medtronic Inc, Minneapolis, Minnesota, US) was deployed at 14atms (Fig. 1B). A repeat IVUS run showed 25% residual DS, MLD of 4.53 mm with MLA of 16.15 mm2 (Fig. 1E). The stented segment was post-dilated with 6 × 20 mm peripheral balloon (Submarine Rapido PTA balloon, Medtronic Inc.) at 17 atms. There was TIMI-3 flow in RCA with no residual stenosis (Fig. 1C). A repeat IVUS run showed MLD of 5.19 mm, MLA of 18.05 mm2 and a well apposed stent struts (Fig. 1F, Video 2). Patient was discharged on dual antiplatelet therapy on following day and was asymptomatic at 1- year of follow-up.
There is a technical challenge in performing percutaneous coronary intervention (PCI) of a large diameter coronary artery of >5 mm dimension because of non-availability of appropriate sized coronary stent and balloon. The maximum diameter of presently available coronary stents is of 5 mm (Taxus stent, Boston Scientific Co., Natick, MA, US; and Resolute Onyx, Medtronic Inc.). In such situation, operator has to either oversized the stent with appropriate sized balloon or performs simultaneous kissing balloon dilatation or stenting. An undersized or unexpanded stent has a risk of stent thrombosis and instent re-stenosis,1–3 while oversizing of a stent may result into polymer fracture, stent deformation and impaired local drug kinetics.4–5 Therefore, a thin strut coronary stent of >5 mm size is a necessity during PCI of such a large diameter coronaries, which is presently not available in the market. A selfexpanding stent like STENTYS can be an alternative option in such situations.6 A peripheral bare metal stent implantation in coronaries is an off-label use; the safety and efficacy of which should be extrapolated with caution. Author (RV) had personal experience of 3-such patients in the past, in whom a peripheral bare metal stent of >5 mm size was implanted and all had favorable long term clinical outcome. In such situation, intra-vascular imaging helps in PCI optimization, while visual or QCA estimated lesion assessment can be fallacious. In conclusion, the index case had demonstrated a successful IVUS supported PCI of a large RCA lesion of 6 mm dimension, by using a balloon-expandable peripheral bare metal stent.
∗ Corresponding author. E-mail address: [email protected] (R. Vijayvergiya). https://doi.org/10.1016/j.ihjccr.2018.02.004 2468-600X/© 2018 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
R. Vijayvergiya et al. / IHJ Cardiovascular Case Reports (CVCR) 2 (2018) 106–107
107
Fig. 1. Percutaneous coronary intervention details of distal right coronary artery (RCA) lesion. A. Coronary angiogram showing discrete 80% stenosis of distal RCA. B. Coronary angiogram following a 6 × 20 mm stent deployment, showing residual stenosis. C. Coronary angiogram following post- dilatation with 6 mm balloon, showing TIMI-3 flow with no residual stenosis. D. Intravascular ultrasound finding corresponding to figure A, showing 76% diameter stenosis (S) of distal RCA. E. Intravascular ultrasound finding corresponding to figure B, showing 25% residual diameter stenosis. F. Intravascular ultrasound finding corresponding to figure C, showing 5.19 mm minimal luminal diameter, 18.05 mm2 minimal luminal area, and well apposed stent struts. Abbreviations: DS-diameter stenosis; MLA-minimal luminal area; MLD-minimal luminal diameter; RVA-reference vessel area; RVD-reference vessel diameter.
Conflict of interest We have no conflict of interest. Acknowledgment There is no funding from any agency or institution was taken for this manuscript. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.ihjccr.2018.02.004. References 1. Uren NG, Schwarzacher SP, Metz JA, et al. POST Registry Investigators: Predictors and outcomes of stent thrombosis: an intravascular ultrasound registry. Eur Heart J. 2002;23:124–132.
2. Fujii K, Carlier SG, Mintz GS, et al. Stent underexpansion and residual reference segment stenosis are related to stent thrombosis after sirolimus-eluting stent implantation: an intravascular ultrasound study. J Am Coll Cardiol. 2005;45:995–998. 3. Bertrand OF, De Larochellière R, Joyal M, Bonan R, Mongrain R, Tardif JC. Incidence of stent under-deployment as a cause of in-stent restenosis in long stents. Int J Cardiovasc Imaging. 2004;20:279–284. 4. Guérin P, Pilet P, Finet G, et al. Drug-eluting stents in bifurcations: bench study of strut deformation and coating lesions. Circ Cardiovasc Interv. 2010;3:120–126. 5. Ng J, Foin N, Ang HY, et al. Over-expansion capacity and stent design model: An update with contemporary DES platforms. Int J Cardiol. 2016;221:171–179. 6. Lu H, I.Jsselmuiden AJ, Grundeken MJ, et al. First-in-man evaluation of the novel balloon delivery system STENTYS Xposition S for the self-apposing coronary artery stent: impact on longitudinal geographic miss during stenting. EuroIntervention. 2016;11:1341–1345.