Abstract
This case report demonstrates a unique strategy requiring a 2.5 mm burr to treat in-stent restenosis of an originally underexpanded stent, implanted in a heavily calcified lesion within a giant aneurysm by Kawasaki disease. Despite our procedural success, it should be emphasized that stent implantation in undilatable lesions should be avoided. When an angiographically calcified lesion within an ectatic segment is observed in a patient with Kawasaki disease, it is recommended that the operator evaluates in detail the severity and location of calcification using intravascular ultrasound imaging and pays meticulous attention to lesion preparation.
1
Introduction
In the majority of cases, in-stent restenosis (ISR) is the result of excessive neointima proliferation or neoatherosclerosis. However, in a previous underexpanded stent, even mild neointima proliferation can lead to ISR. Stent under-expansion is an important trigger both for ISR and stent thrombosis, thus good lesion preparation is of ultimate importance prior to stent implantation .
Coronary artery stenoses in patients with Kawasaki disease are commonly severely calcified, in contrast to the majority of adult atheromatous coronary artery lesions . While conventional balloon angioplasty can be attempted, heavily calcified lesions may prevent adequate lesion preparation and subsequent stent expansion. This case report describes the successful treatment of ISR of a previously underexpanded stent due to calcification, using rotational atherectomy.
2
Case report
A 35-year-old male was referred to our hospital for coronary angiography. He had a past medical history of Kawasaki disease complicated by coronary aneurysms. He was first diagnosed at the age of 26 years when he presented with acute antero-septal myocardial infarction in the absence of any coronary risk factors. He underwent emergency coronary angiography at another institution, which documented acute thrombotic occlusion within an aneurysm in the left anterior descending artery (LAD) and a large aneurysm of the distal left main. He underwent delayed primary percutaneous coronary intervention (PCI) with implantation of a bare metal stent (BMS) in the ectatic segment of the mid-LAD. At that point, the procedure report mentions underexpansion at the proximal and distal neck of the LAD aneurysm despite high-pressure dilatation. He underwent repeat coronary angiography 6-months later, which confirmed patency of the stent and 40%–50% stenosis at the proximal and distal ends of the aneurysm. Given this suboptimal angiographic result, nine years after his index PCI, he underwent control coronary computed tomography (CT) in order to reevaluate his coronary anatomy. Coronary CT showed aneurysmal dilatation of the distal left main and mid-LAD with severe calcific stenosis (80%) in the latter. We therefore proceeded to invasive coronary angiography with a view to perform PCI if the lesion identified by CT was proven to be critical.
Coronary angiography, performed via the right femoral artery, demonstrated ISR in the middle LAD ( Fig. 1 -A, B, C ) within a giant, heavily calcified aneurysm ( Fig. 1 -D). After crossing the lesion with a Balance Middleweight universal coronary guide wire (Abott Vascular, Santa Clara, CA, USA), balloon dilatation with a non-compliant balloon was performed. As this failed to expand fully, evident by the presence of “dog-boning” during nominal pressure inflation, we proceeded to intravascular ultrasound (IVUS) (40-MHz IVUS catheter, Boston Scientific Corp) imaging, in order to better understand the underlying lesion morphology. This revealed heavy circumferential calcification under the previously implanted stent with a minimum stent area (MSA) of 3.73 mm 2 within the giant aneurysm ( Fig. 1 -b). We then proceeded to further balloon dilatation with an ultra-high pressure OPN NC balloon (SIS-Medical AG, Winterthur, Switzerland, rated burst pressure 35 atm). The twin-layer balloon technology used in OPN NC balloon, helps to ensure uniform expansion. Multiple inflations (3.5 × 10 mm at 42 atm) with this balloon were proven to be ineffective, and eventually led to balloon rupture. We therefore chose to use rotational atherectomy (RA) (Boston Scientific, USA) using a 2.0-mm burr, followed by further OPN NC balloon inflation (3.5 × 10 mm at 42 atm). Despite using RA, marked residual balloon indentation was still evident and IVUS did not demonstrate any significant improvement ( Fig. 2 -I /II). At this stage we decided to proceed with excimer laser coronary angioplasty (ELCA). The ELCA catheter (Turbo Elite catheter®, 1.7 mm; Spectranetics Corporation, Colorado Springs, CO, USA) was passed over the guide-wire, then inserted within the stent and advanced slowly toward the underexpanded zone. ELCA ablation was performed with contrast injection at the highest fluency and repetition rates. Unfortunately, the indentation in the OPN NC balloon was still present despite inflation at 42 atm ( Fig. 2 -III). IVUS confirmed the angiographic findings as there were no significant improvement in MSA (3.75 mm 2 ; Fig. 2 -IV). As a last resort, we opted to re-attempt RA but on this occasion with a 2.5 mm burr. This required the use of a 9Fr guiding catheter. Eventually, this proved to be successful with marked improvement in balloon expansion at the lesion site (3.5 × 20 mm OPN NC balloon at 40 atm) ( Fig. 2 -V). MSA also significantly improved from 3.75 mm 2 to 6.06 mm 2 , representing an almost 100% increase ( Fig. 2 -VI). IVUS demonstrated deformed stent struts on the path of the rotablator burr. At the end of the procedure a drug-eluting balloon (3.5 × 20 mm IN.PACT; Medtronic Invatec, Frauenfeld, Switzerland) was applied at the lesion site. Final angiography and IVUS findings indicated an excellent result ( Fig. 3 ).
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