Abstract
A 43 year-old male, with a long history of coronary artery disease, was electively admitted to our institution because of dyspnea for moderate physical efforts (NYHA 2) related to an in-stent chronic total occlusion of ostial RCA and with demonstration of a significant area of inducible myocardial ischemia at stress echocardiography. After a gentle attempt of antegrade approach, the in-stent CTO of ostial RCA was successfully reopened with a retrograde approach using a knuckle technique. After IVUS evaluation which showed that the course of the retrograde guidewire was mostly within the stent strut circumference with the exception of the ostial RCA where the guidewire past between the stent and the vessel wall, implantation of 4 drug-eluting stent was performed from mid to ostial RCA with a good final result. The hospital stay was uneventful. At 6 months clinical follow-up the patient was in good clinical condition. We discuss some aspects related to procedural technique, the importance of IVUS evaluation in the treatment of this patient.
Highlights
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In-stent restenosis leading to coronary chronic total occlusion (ISR-CTO) is an uncommon problem in clinical practice
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The reported incidence of ISR-CTO ranges from 5% to 10% of all CTO-PCI and the percutaneous treatment of ISR-CTO has a lower procedural success rate than conventional CTO. In this setting the use of intravascular ultrasound is of paramount importance.
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We describe a case of a 43-year old male patient with a long-in stent CTO of ostial right coronary artery treated with retrograde approach highlighting the importance of IVUS evaluation in the treatment of this patient.
1
Introduction
In-stent restenosis leading to coronary chronic total occlusion (ISR-CTO) is an uncommon problem in clinical practice. The reported incidence of ISR-CTO ranges from 5% to 10% of all CTO-PCI . Moreover the percutaneous treatment of ISR-CTO has a lower procedural success rates than conventional CTO . In this setting the use of IVUS is of paramount importance.
2
Case report
A 43 year-old man, with a familial hypercholesterolemia and a long history of coronary artery disease starting from 2006 with several hospital admissions for acute coronary syndrome treated with multiple percutaneous revascularizations, was evaluated in July 2015 because of dyspnea for moderate physical efforts (NYHA 2) and reduced exercise tolerance, but without symptoms of angina. The physical examination was unremarkable. The basal ECG showed a sinus bradycardia 54 beats per minute, with Q waves in DIII and aVF. The basal echocardiogram showed an hypokinesia of basal interventricular septum, an inferior and posterior wall hypokinesia with a globally preserved left ventricular systolic function (EF = 55%). During the last hospital admission, the coronary angiography documented a well patency of previously implanted stents in the left main, proximal left anterior descending and intermediate ramus and an in-stent chronic total occlusion (CTO) of ostial right coronary artery (RCA). Since the ECG showed the presence of Q waves, the patient underwent to stress echocardiogram with dobutamine infusion that revealed a significant area of inducible ischemia in basal and mid segments of posterior wall. The patient was scheduled for an attempt of reopening the in-stent CTO of ostial RCA.
In September 2015, the patient underwent to the attempt of reopening the in-stent CTO of ostial RCA ( Fig. 1 A ). Two long sheats 7F 45 cm (Destination, Terumo, Japan) were positioned in right and left femoral arteries. An AL 1 7F and an EBU 4 7F 90 cm guiding catheters (Launcher, Medtronic, MN, USA), were positioned respectively in the RCA and in the left coronary artery. Despite anchoring balloon in the conus branch of the RCA, the AL 1 guide catheter was neither stable nor coaxial and was substituted with a JR 4 7F guide catheter. After achieving an increased coaxiality with this latter guide catheter and an anchoring balloon in the conus branch of the RCA, a gentle attempt of antegrade approach was performed without success ( Fig. 1 B). Thereafter we decided to shift to a retrograde approach. We advanced the Corsair 150 cm microcatheter on a Sion Blue guidewire (Asahi Intecc, Japan) into a third septal branch. We negotiated with the Sion Blue guidewire a secondary septal branch and the tip injection through the Corsair showed a clear connection with the posterior descending of the RCA through a very tortuous septal ( Fig. 1 C). The Sion Blue was exchanged for a Fielder XT-R guidewire (Asahi Intecc, Japan) which, navigating within the most tortuous pathway of the septal branch, reached the posterior descending of the RCA ( Fig. 1 D). The Fielder XT-R guidewire was advanced within the in-stent CTO with a close J-loop configuration according to the knuckle technique until to the ascending aorta ( Fig. 1 E). The Corsair 150 was advanced within the in-stent CTO closely to the proximal cap. The Fielder XT-R was exchanged for a Sion guidewire that easily entered the JR 4 7F guide catheter ( Fig. 1 F). Then we advanced with much resistance the Corsair 150 cm within the JR 4 7F guide catheter and, after balloon trapping of the Corsair 150 cm, a RG 330 cm guidewire was externalized. Balloon predilatation of the in-stent CTO was performed using first a 2.0 × 15 mm which was advanced with some resistance within the ostial RCA. Further balloon predilatations were performed with a 2.5 × 20 mm and 3.0 × 20 non compliant balloons in mid and proximal RCA but not in the ostium. According to our protocol, contrast medium injection through the antegrade guide catheter was avoided and, in order to visualize the vessel, IVUS evaluation (Eagle Eye, Volcano Corporation, Japan) was performed over the RG3 guidewire externalized. Interestingly IVUS showed that the course of the retrograde guidewire was mostly within the stent strut circumference with the exception of the ostial RCA where the retrograde guidewire was outside the stent strut circumference and precisely located between the original underexpanded stent and the vessel wall ( Fig. 2 ). In this situation contrast medium injection through the antegrade guiding catheter is absolutely contraindicated because it could determine iatrogenic aortic dissection with catastrophic consequences. After IVUS evaluation, a first drug-eluting stent 3.5 × 28 mm (Ultimaster, Terumo, Japan) was implanted in mid RCA ( Fig. 3 A ). A second drug-eluting stent 3.5 × 24 mm (Ultimaster, Terumo, Japan) was implanted proximally and in overlapping with the first stent ( Fig. 3 B). A third drug-eluting stent 3.5 × 18 mm (Ultimaster, Terumo, Japan) was implanted in proximal RCA and in overlapping with the second stent ( Fig. 3 C). After a new IVUS evaluation, a fourth drug-eluting stent 4.0 × 9 mm (Ultimaster, Terumo, Japan) was implanted in overlapping with the third stent in the true RCA ostium ( Fig. 3 D), partially crushing the most proximal struts of the old stent. The long stented segment was post-dilated with a 4.0 × 15 non-compliant balloon starting from 16 atm in mid RCA until to 26 atm in ostial RCA. Plain old balloon angioplasty with a 2.5 × 20 mm non-compliant balloon was performed in distal RCA that appeared smaller than the mid-proximal tract. Final IVUS run showed the optimal expansion and apposition of the implanted stents and the absence of significant disease in distal RCA. The final result was good ( Fig. 4 ).
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