Abstract
We report the case of a 77-year-old male patient who was admitted to our institution for non-ST segment elevation myocardial infarction. Coronary angiography showed a sub-occlusive lesion of the distal left anterior descending artery (LAD) in the context of a diffuse atherosclerotic disease involving a very long segment of the vessel (about 80 mm in length by visual estimation). Pre-dilatation was performed in the mid calcified segment of the LAD with a non-compliant balloon inducing vessel dissection. An everolimus-eluting bioresorbable vascular scaffold (EEBVS) was then advanced in the LAD but the first delivery attempt at the distal site failed because of friction between the EEBVS struts and the calcified vessel wall. In order to facilitate EEBVS delivery, a 5Fr catheter system (Heart Rail II, Terumo, Tokyo, Japan) was advanced in the mid LAD within a standard 6Fr guiding catheter facilitating a non-traumatic deep intubation up to the mid LAD. This strategy increased back-up support facilitating the delivery, beyond the site of resistance, of four EEBVS implanted in overlap. This case demonstrated the successful use of a guide catheter extension system to deliver multiple EEBVS in a patient with a long, calcified LAD lesion.
1
Introduction
The traditional metallic stents have significant limitations as they predispose to late thrombosis, may preclude surgical revascularization and distort vessel physiology. Bioresorbable vascular scaffolds (BVS) are a relatively new technology introduced to overcome these drawbacks. BVS could offer transient radial strength to resist acute vessel recoil and later would be fully resorbed, leading to restoration of the vessel’s biological properties . Recently, the ABSORB endoprosthesis (Abbott Vascular, Santa Clara, California) became the first BVS commercially available in Europe. However there are currently limited data on the use of this device in routine clinical practice, particularly in complex cases. This report describes the successful implantation of multiple overlapped ABSORB BVS facilitated by a guiding catheter extension system in the setting of a long, tapered and resistant coronary lesion.
2
Case report
A 77-year-old male hypercholesterolemic, hypertensive, non-insulin dependent diabetic with a history of previous percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation in the mid left circumflex, second obtuse marginal and right coronary arteries was admitted to our institution for non-ST segment elevation myocardial infarction. Coronary angiography showed a sub-occlusive lesion of the distal left anterior descending artery (LAD) in the context of diffuse atherosclerotic disease involving a very long segment of the vessel (about 80 mm in length with proximal and distal references of 3.0 and 2.5 mm by visual estimation) ( Fig. 1 A ). In order to avoid a “full metal jacket” PCI with permanent DES involving the distal LAD, we planned to treat the lesion with multiple overlapped ABSORB everolimus-eluting bioresorbable vascular scaffold (EEBVS). A coronary guide-wire (Sion, Asahi Intecc Co, LTD, Nagoya, Japan) was placed distally in the LAD. A calcified segment of the mid LAD ( Fig. 1 A; arrows) presented significant resistance to the passage of the pre-dilatation balloons (2.0 × 15 mm and 1.25 × 15 mm). Therefore, it was decided to aggressively dilate this segment with a non-compliant balloon in order to prepare for the introduction of BVS. The dilatation that was performed with a non-compliant balloon (2.5 × 20 mm at 16 atm) induced vessel dissection ( Fig. 1 B). A 2.5 × 18 mm EEBVS was advanced in the LAD but the first deliver attempt at the distal site failed because of friction between the EEBVS struts and the calcified vessel wall. In order to avoid manipulations of the scaffold, an alternative strategy was used and a 5Fr 120 cm long catheter (Heart Rail II, Terumo, Tokyo, Japan) was advanced in the mid LAD within a standard 100 cm 6Fr (“child in mother” technique) guiding catheter (Extra Back-Up 3.5, Medtronic Inc., Minneapolis, USA) ( Fig. 2 A ). This strategy facilitated a non-traumatic deep intubation up to the mid LAD few (< 5) millimeters beyond the point at which friction was initially generated, thereby bypassing the point of resistance and facilitating the delivery of four EEBVS of increasing diameters (from distal to proximal segment: 2.5 × 18 mm, 2.5 × 28 mm, 3.0 × 28 mm and 3.0 × 18 mm) implanted in overlap. The EEBVS were deployed at 10 atm and the overlap was obtained almost aligning the distal radiopaque marker (positioned 0.7 mm proximally to the distal edge) of the proximal EEBVS with the proximal radiopaque marker (positioned 1.4 mm distally to the proximal edge) of the distal EEBVS (see Fig 2 B). EEBVS post-dilatation to ensure a good scaffold apposition was performed with NC balloons (2.75 × 20 mm at 14 atm in the distal 2.5 mm BVSs and 3.25 × 20 mm at 18 atm in the 3.0 proximal BVSs). The final angiogram showed a good result (all the LAD branches were maintained) without angiographic complications (i.e. further dissection in the proximal LAD) associated to the deep vessel intubation ( Fig. 3 ). The patient was discharged the day after PCI on dual anti-platelet therapy (aspirin 100 mg daily and clopidorel 75 mg daily) for 12 months. He has remained asymptomatic and free from cardiac events since the procedure in January 2013. The patient is scheduled for follow-up coronary angiogram and intracoronary imaging analysis in June 2014 (18-months after their index procedure). The decision has been made in keeping with the previous studies that have exhibited the time duration for complete absorption of these scaffolds, which ranges from 18 to 24 months . However, the patients is under routine clinical follow-up (every 6-months) and will be considered earlier imaging, if clinically indicated (recurrence of angina or if they sustain myocardial infarction).
2
Case report
A 77-year-old male hypercholesterolemic, hypertensive, non-insulin dependent diabetic with a history of previous percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation in the mid left circumflex, second obtuse marginal and right coronary arteries was admitted to our institution for non-ST segment elevation myocardial infarction. Coronary angiography showed a sub-occlusive lesion of the distal left anterior descending artery (LAD) in the context of diffuse atherosclerotic disease involving a very long segment of the vessel (about 80 mm in length with proximal and distal references of 3.0 and 2.5 mm by visual estimation) ( Fig. 1 A ). In order to avoid a “full metal jacket” PCI with permanent DES involving the distal LAD, we planned to treat the lesion with multiple overlapped ABSORB everolimus-eluting bioresorbable vascular scaffold (EEBVS). A coronary guide-wire (Sion, Asahi Intecc Co, LTD, Nagoya, Japan) was placed distally in the LAD. A calcified segment of the mid LAD ( Fig. 1 A; arrows) presented significant resistance to the passage of the pre-dilatation balloons (2.0 × 15 mm and 1.25 × 15 mm). Therefore, it was decided to aggressively dilate this segment with a non-compliant balloon in order to prepare for the introduction of BVS. The dilatation that was performed with a non-compliant balloon (2.5 × 20 mm at 16 atm) induced vessel dissection ( Fig. 1 B). A 2.5 × 18 mm EEBVS was advanced in the LAD but the first deliver attempt at the distal site failed because of friction between the EEBVS struts and the calcified vessel wall. In order to avoid manipulations of the scaffold, an alternative strategy was used and a 5Fr 120 cm long catheter (Heart Rail II, Terumo, Tokyo, Japan) was advanced in the mid LAD within a standard 100 cm 6Fr (“child in mother” technique) guiding catheter (Extra Back-Up 3.5, Medtronic Inc., Minneapolis, USA) ( Fig. 2 A ). This strategy facilitated a non-traumatic deep intubation up to the mid LAD few (< 5) millimeters beyond the point at which friction was initially generated, thereby bypassing the point of resistance and facilitating the delivery of four EEBVS of increasing diameters (from distal to proximal segment: 2.5 × 18 mm, 2.5 × 28 mm, 3.0 × 28 mm and 3.0 × 18 mm) implanted in overlap. The EEBVS were deployed at 10 atm and the overlap was obtained almost aligning the distal radiopaque marker (positioned 0.7 mm proximally to the distal edge) of the proximal EEBVS with the proximal radiopaque marker (positioned 1.4 mm distally to the proximal edge) of the distal EEBVS (see Fig 2 B). EEBVS post-dilatation to ensure a good scaffold apposition was performed with NC balloons (2.75 × 20 mm at 14 atm in the distal 2.5 mm BVSs and 3.25 × 20 mm at 18 atm in the 3.0 proximal BVSs). The final angiogram showed a good result (all the LAD branches were maintained) without angiographic complications (i.e. further dissection in the proximal LAD) associated to the deep vessel intubation ( Fig. 3 ). The patient was discharged the day after PCI on dual anti-platelet therapy (aspirin 100 mg daily and clopidorel 75 mg daily) for 12 months. He has remained asymptomatic and free from cardiac events since the procedure in January 2013. The patient is scheduled for follow-up coronary angiogram and intracoronary imaging analysis in June 2014 (18-months after their index procedure). The decision has been made in keeping with the previous studies that have exhibited the time duration for complete absorption of these scaffolds, which ranges from 18 to 24 months . However, the patients is under routine clinical follow-up (every 6-months) and will be considered earlier imaging, if clinically indicated (recurrence of angina or if they sustain myocardial infarction).
