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Optical coherence tomography guided treatment of recurrent drug-eluting stent failure using drug-eluting balloon
International Journal of Cardiology 221 (2016) 32–33
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Optical coherence tomography guided treatment of recurrent drug-eluting stent failure using drug-eluting balloon☆ George Latsios, Antonios Karanasos, Konstantinos Toutouzas, Georgia Vogiatzi, Spyridon Papaioannou, Andreas Synetos, Dimitris Tousoulis ⁎ 1st Department of Cardiology, Medical School, University of Athens, Hippokration Hospital, Athens, Greece
a r t i c l e
i n f o
Article history: Received 30 June 2016 Accepted 2 July 2016 Available online 3 July 2016
Keywords: Optical coherence tomography Angioplasty Stent Drug eluting stent
A 52-year old gentleman was admitted to our department to undergo catheterization due to recent onset stable angina in minimal effort. He had a history of myocardial infarction 10 years ago, with coronary artery bypass graft surgery 8 years ago. A left internal mammary artery (LIMA) graft had been anastomosed in the midleft anterior descending (LAD) artery and two saphenous vein grafts (SVGs) in the left circumflex (LCx) and the right coronary artery (RCA), respectively. Six years ago, he underwent percutaneous coronary intervention (PCI) of the native LCx, with implantation of two overlapping second generation drug-eluting stents (DES), due to occlusion of the corresponding SVG graft. Four years ago, he presented with stable angina due to in-stent restenosis of the LCx stents, and two additional second generation DES were implanted in the restenotic lesion. Coronary angiography revealed a patent LIMA to a more proximal occluded LAD, while both of the SVGs were found to be occluded as well. The LCx was patent with TIMI flow III, however two focal hazy spots were observed (arrows; Fig. 1A). In order to elucidate these angiographic findings, an optical coherence tomography (OCT) study was performed in the stented segment (Dragonfly Duo™ catheter and Optis™ system; St. Jude/Lightlab, St. Paul, MN, USA). The OCT study ☆ All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ⁎ Corresponding author at: 1st Department of Cardiology, University of Athens Medical School, 114 Vas. Sofias Ave., 11527 Athens, Greece. E-mail address: [email protected] (D. Tousoulis).
http://dx.doi.org/10.1016/j.ijcard.2016.07.007 0167-5273/© 2016 Published by Elsevier Ireland Ltd.
showed no thrombus within the studied segment; however two short restenotic near-occlusive regions were observed: one with the underexpansion of the previously implanted stents due to the presence of calcium deep in the coronary artery wall (Fig. 1B) and one with excessive heterogeneous tissue coverage (Fig. 1C). Seeing the absence of thrombus or in-stent neoatherosclerosis, and considering the jailing of the vessel with multiple stent layers, preventing the full expansion of a new stent, it was decided to proceed with PCI of the stented lesion with a very high pressure balloon inflation. A 3.0 × 20 mm non-compliant balloon was inflated at 28 atm, and the lesion was subsequently treated with multiple 3.0 × 16 mm paclitaxel-eluting balloons, inflated at 8 atm for at least 60 s (Pantera Lux™, Biotronik AG, Buelach, Switzerland), with a good angiographic result (Fig. 1A’). A repeat OCT was performed to evaluate the final result, showing an improvement of the expansion of the previously-implanted stents (Fig. 1B’), and a complete compression of the in-stent tissue (Fig. 1C’), resulting in a good lumen gain without any in-stent tissue flaps. The patient was discharged symptom-free on dual antiplatelet therapy. Although the incidence of DES restenosis is not very high, it comprises a difficult clinical problem, as it is associated with adverse outcomes and increased recurrence rates [1]. Various treatments have been tested, however event rates remain high [2]. The use of intracoronary imaging has been proposed as a means to evaluate the underlying substrate of stent failure and use the information in order to individualize treatment [3–5]. In our case, intracoronary imaging by OCT helped us identify the presence of in-stent restenosis as a culprit for the symptoms of the patient, as the angiographic images were inconclusive. Moreover, OCT identified suboptimal expansion as the main substrate for the restenosis and excluded the presence of in-stent thrombus, homogeneous neointimal proliferation, or neoatherosclerosis as a pathological substrate [6,7], guiding us to adapt a treatment strategy that alleviates the need for an additional stent layer, which could lead to further lumen narrowing in an already caged vessel [8]. The final pullback confirmed a good implantation result, without the need for additional stent implantation. Overall, our case highlights the utility of intracoronary imaging in recurrent DES failure for guiding the selection of treatment strategy, suggesting a need to tailor treatment based on the underlying substrate.
Correspondence
33
Fig. 1. A. Coronary angiography of the left circumflex artery revealed two hazy spots (arrows). Optical coherence tomography (OCT) revealed occlusive restenosis in both sites due to B. Underexpansion in a site with deeply located calcium (Ca) and to C. heterogeneous tissue coverage (Het). A’. Coronary angiography after PCI showing no lumen deficits. OCT images of corresponding sites showing B’. Improvement of the expansion and C’ compression of the in-stent heterogeneous tissue.
Conflict of interest No conflicts of interest to disclose for any author. [5]
References [1] G.D. Dangas, B.E. Claessen, A. Caixeta, E.A. Sanidas, G.S. Mintz, R. Mehran, In-stent restenosis in the drug-eluting stent era, J. Am. Coll. Cardiol. 56 (2010) 1897–1907. [2] F. Alfonso, M.J. Perez-Vizcayno, A. Cardenas, B. Garcia del Blanco, A. Garcia-Touchard, J.R. Lopez-Minguez, et al., A prospective randomized trial of drug-eluting balloons versus everolimus-eluting stents in patients with In-stent restenosis of drug-eluting stents: the RIBS IV randomized clinical trial, J. Am. Coll. Cardiol. 66 (2015) 23–33. [3] A. Karanasos, J. Ligthart, K. Witberg, G. van Soest, N. Bruining, E. Regar, Optical coherence tomography: potential clinical applications, Curr. Cardiovasc. Imaging Rep. 5 (2012) 206–220. [4] S. Windecker, P. Kolh, F. Alfonso, J.P. Collet, J. Cremer, V. Falk, et al., 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial
[6]
[7] [8]
revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), Eur. Heart J. 35 (2014) 2541–2619. A. Karanasos, N. Van Mieghem, N. van Ditzhuijzen, C. Felix, J. Daemen, A. Autar, et al., Angiographic and optical coherence tomography insights into bioresorbable scaffold thrombosis: single-center experience, Circ. Cardiovasc. Interv. 8 (2015). A. Karanasos, J.M. Ligthart, E. Regar, In-stent neoatherosclerosis: a cause of late stent thrombosis in a patient with “full metal jacket” 15 years after implantation: insights from optical coherence tomography, JACC Cardiovasc. Interv. 5 (2012) 799–800. B.C. Zhang, A. Karanasos, E. Regar, OCT demonstrating neoatherosclerosis as part of the continuous process of coronary artery disease, Herz 40 (2015) 845–854. A. Karanasos, C. Simsek, M. Gnanadesigan, N.S. van Ditzhuijzen, R. Freire, J. Dijkstra, et al., OCT assessment of the long-term vascular healing response 5 years after everolimus-eluting bioresorbable vascular scaffold, J. Am. Coll. Cardiol. 64 (2014) 2343–2356.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Optical coherence tomography guided treatment of recurrent drug-eluting stent failure using drug-eluting balloon☆ George Latsios, Antonios Karanasos, Konstantinos Toutouzas, Georgia Vogiatzi, Spyridon Papaioannou, Andreas Synetos, Dimitris Tousoulis ⁎ 1st Department of Cardiology, Medical School, University of Athens, Hippokration Hospital, Athens, Greece
a r t i c l e
i n f o
Article history: Received 30 June 2016 Accepted 2 July 2016 Available online 3 July 2016
Keywords: Optical coherence tomography Angioplasty Stent Drug eluting stent
A 52-year old gentleman was admitted to our department to undergo catheterization due to recent onset stable angina in minimal effort. He had a history of myocardial infarction 10 years ago, with coronary artery bypass graft surgery 8 years ago. A left internal mammary artery (LIMA) graft had been anastomosed in the midleft anterior descending (LAD) artery and two saphenous vein grafts (SVGs) in the left circumflex (LCx) and the right coronary artery (RCA), respectively. Six years ago, he underwent percutaneous coronary intervention (PCI) of the native LCx, with implantation of two overlapping second generation drug-eluting stents (DES), due to occlusion of the corresponding SVG graft. Four years ago, he presented with stable angina due to in-stent restenosis of the LCx stents, and two additional second generation DES were implanted in the restenotic lesion. Coronary angiography revealed a patent LIMA to a more proximal occluded LAD, while both of the SVGs were found to be occluded as well. The LCx was patent with TIMI flow III, however two focal hazy spots were observed (arrows; Fig. 1A). In order to elucidate these angiographic findings, an optical coherence tomography (OCT) study was performed in the stented segment (Dragonfly Duo™ catheter and Optis™ system; St. Jude/Lightlab, St. Paul, MN, USA). The OCT study ☆ All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ⁎ Corresponding author at: 1st Department of Cardiology, University of Athens Medical School, 114 Vas. Sofias Ave., 11527 Athens, Greece. E-mail address: [email protected] (D. Tousoulis).
http://dx.doi.org/10.1016/j.ijcard.2016.07.007 0167-5273/© 2016 Published by Elsevier Ireland Ltd.
showed no thrombus within the studied segment; however two short restenotic near-occlusive regions were observed: one with the underexpansion of the previously implanted stents due to the presence of calcium deep in the coronary artery wall (Fig. 1B) and one with excessive heterogeneous tissue coverage (Fig. 1C). Seeing the absence of thrombus or in-stent neoatherosclerosis, and considering the jailing of the vessel with multiple stent layers, preventing the full expansion of a new stent, it was decided to proceed with PCI of the stented lesion with a very high pressure balloon inflation. A 3.0 × 20 mm non-compliant balloon was inflated at 28 atm, and the lesion was subsequently treated with multiple 3.0 × 16 mm paclitaxel-eluting balloons, inflated at 8 atm for at least 60 s (Pantera Lux™, Biotronik AG, Buelach, Switzerland), with a good angiographic result (Fig. 1A’). A repeat OCT was performed to evaluate the final result, showing an improvement of the expansion of the previously-implanted stents (Fig. 1B’), and a complete compression of the in-stent tissue (Fig. 1C’), resulting in a good lumen gain without any in-stent tissue flaps. The patient was discharged symptom-free on dual antiplatelet therapy. Although the incidence of DES restenosis is not very high, it comprises a difficult clinical problem, as it is associated with adverse outcomes and increased recurrence rates [1]. Various treatments have been tested, however event rates remain high [2]. The use of intracoronary imaging has been proposed as a means to evaluate the underlying substrate of stent failure and use the information in order to individualize treatment [3–5]. In our case, intracoronary imaging by OCT helped us identify the presence of in-stent restenosis as a culprit for the symptoms of the patient, as the angiographic images were inconclusive. Moreover, OCT identified suboptimal expansion as the main substrate for the restenosis and excluded the presence of in-stent thrombus, homogeneous neointimal proliferation, or neoatherosclerosis as a pathological substrate [6,7], guiding us to adapt a treatment strategy that alleviates the need for an additional stent layer, which could lead to further lumen narrowing in an already caged vessel [8]. The final pullback confirmed a good implantation result, without the need for additional stent implantation. Overall, our case highlights the utility of intracoronary imaging in recurrent DES failure for guiding the selection of treatment strategy, suggesting a need to tailor treatment based on the underlying substrate.
Correspondence
33
Fig. 1. A. Coronary angiography of the left circumflex artery revealed two hazy spots (arrows). Optical coherence tomography (OCT) revealed occlusive restenosis in both sites due to B. Underexpansion in a site with deeply located calcium (Ca) and to C. heterogeneous tissue coverage (Het). A’. Coronary angiography after PCI showing no lumen deficits. OCT images of corresponding sites showing B’. Improvement of the expansion and C’ compression of the in-stent heterogeneous tissue.
Conflict of interest No conflicts of interest to disclose for any author. [5]
References [1] G.D. Dangas, B.E. Claessen, A. Caixeta, E.A. Sanidas, G.S. Mintz, R. Mehran, In-stent restenosis in the drug-eluting stent era, J. Am. Coll. Cardiol. 56 (2010) 1897–1907. [2] F. Alfonso, M.J. Perez-Vizcayno, A. Cardenas, B. Garcia del Blanco, A. Garcia-Touchard, J.R. Lopez-Minguez, et al., A prospective randomized trial of drug-eluting balloons versus everolimus-eluting stents in patients with In-stent restenosis of drug-eluting stents: the RIBS IV randomized clinical trial, J. Am. Coll. Cardiol. 66 (2015) 23–33. [3] A. Karanasos, J. Ligthart, K. Witberg, G. van Soest, N. Bruining, E. Regar, Optical coherence tomography: potential clinical applications, Curr. Cardiovasc. Imaging Rep. 5 (2012) 206–220. [4] S. Windecker, P. Kolh, F. Alfonso, J.P. Collet, J. Cremer, V. Falk, et al., 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial
[6]
[7] [8]
revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), Eur. Heart J. 35 (2014) 2541–2619. A. Karanasos, N. Van Mieghem, N. van Ditzhuijzen, C. Felix, J. Daemen, A. Autar, et al., Angiographic and optical coherence tomography insights into bioresorbable scaffold thrombosis: single-center experience, Circ. Cardiovasc. Interv. 8 (2015). A. Karanasos, J.M. Ligthart, E. Regar, In-stent neoatherosclerosis: a cause of late stent thrombosis in a patient with “full metal jacket” 15 years after implantation: insights from optical coherence tomography, JACC Cardiovasc. Interv. 5 (2012) 799–800. B.C. Zhang, A. Karanasos, E. Regar, OCT demonstrating neoatherosclerosis as part of the continuous process of coronary artery disease, Herz 40 (2015) 845–854. A. Karanasos, C. Simsek, M. Gnanadesigan, N.S. van Ditzhuijzen, R. Freire, J. Dijkstra, et al., OCT assessment of the long-term vascular healing response 5 years after everolimus-eluting bioresorbable vascular scaffold, J. Am. Coll. Cardiol. 64 (2014) 2343–2356.