Abstract
The advent of drug-eluting stents (DES) associated with improvements in interventional techniques, encouraged the use of percutaneous coronary intervention (PCI) for unprotected left main (ULM) stenosis because of the lower need of repeat revascularization compared to the bare-metal stents (BMS). Nevertheless, ULM DES in-stent restenosis (ISR) continues to occur. The choice of treatment strategy (medical treatment, repeated PCI, or coronary artery bypass graft) for ULM DES-ISR depends primarily on several clinical and angiographic factors, making optimal patient selection crucial in the appropriate treatment of ULM-ISR lesions and achievement of favorable long-term outcomes. We describe in this report a successful modern approach to manage a distal ULM DES-ISR following a 2-stent strategy, consisting in the kissing inflation of two DEBs in both branches of the bifurcation.
1
Introduction
Improvements in stent technology and pharmacotherapies, gave supportive evidence for the use of percutaneous coronary intervention (PCI) in selected patients with unprotected left main (ULM) lesions . Aside from the use of drug-eluting stent (DES), there is no consensual agreement regarding the optimal PCI strategy for unprotected distal left main (UDLM) bifurcation stenosis. Moreover, there are little data available on the treatment of in-stent restenosis (ISR) in this site .
Recently, DEBs have shown good results in the treatment of both bare-metal (BMS) and DES-ISR even at bifurcation site .
We described a modern approach to manage an UDLM DES-ISR following a 2-stent (TAP stenting) strategy, consisting of the kissing inflation of two DEBs in both branches of the bifurcation.
2
Case report
A 70-year old male diabetic who previously underwent PCI with DES (Xience V, Abbott Vascular Devices, Redwood City, CA, USA) implantation on the left circumflex (LCx) and on the unprotected distal left main (UDLM), was admitted to our Institution because of congestive heart failure and left ventricular (LV) dysfunction (EF 35%) due to anterior and lateral wall hypokinesia.
Coronary angiography showed a diffuse DES-ISR on the mid LCx and on the UDLM bifurcation involving both the left anterior descending and LCx ostium. ( Fig. 1 A , B, C) Pre-dilatation was performed at the UDLM toward the proximal and mid LCx with a 3.0×30 mm semi-compliant balloon followed by a 3.0×10 mm cutting-balloon inflation at the ostial LCx. A 3.0×30 mm paclitaxel-eluting balloon (DEB-In.Pact Falcon, Medtronic, Santa Rosa, CA) was inflated at nominal pressures for 60” at the mid LCx. ( Fig. 2 A ) Then 2 DEBs 3.5×30 mm (UDLM-LCx) and 3.0×30 mm (UDLM-LAD) were simultaneously inflated (in a kissing fashion) at nominal pressures for 45” at the UDLM bifurcation ( Fig. 2 B) obtaining a good immediate ( Fig. 2 C) and 9-month angiographic ( Fig. 2 D, E, F) and clinical results.
