Abstract
Optical coherence tomography (OCT) has gained increasing popularity in the recent years. In this case, we documented optimal visualization of four stent layers that were seen during percutaneous coronary intervention for recurrent in-stent restenosis. OCT was clearly able to penetrate all of the neointimal tissue layers extending through to the last stent, which was near the adventitia. Our case demonstrates the excellent utility of OCT for detail assessment of a lesion with multiple stents. To our knowledge, this case is the first case report that could demonstrate excellent visualization of 5 different stent layers using OCT, extending through the deepest stent layer near the adventitia.
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Case report
Our patient was a 66-year-old male with a history of hypertension, hyperlipidemia and coronary artery disease with 4 vessel coronary artery bypass graft surgery in 1991. He had multiple percutaneous coronary interventions (PCI) to his saphenous vein graft (SVG) supplying the diagonal branch for treatment of in-stent restenosis with different types of drug-eluting stents including Paclitaxel, Zotarolimus, and Everolimus. He presented with recurrent unstable angina. His last PCI had been four months earlier when he was again found to have in-stent restenosis and underwent successful PCI with two Everolimus drug-eluting promus stents (3.5 mm × 30 mm and 3.5 mm × 12 mm, Boston Scientific Co., Natick, MA). He had been complaint with his dual-antiplatelet therapy with aspirin and Clopidogrel, which he had been on since his initial PCI. He stated that he had felt well since his last intervention until recently when he experienced recurrent angina with an increase in frequency and intensity in recent days. Based on his known coronary disease and recurrent unstable symptoms, we decided to proceed with repeat cardiac catheterization. His coronary angiography revealed a high-grade in-stent restenosis in the proximal segment of SVG to the diagonal branch ( Fig. 1 ). Based on his recent angiogram four months earlier, which had shown patent left internal mammary artery (LIMA) to left anterior descending artery and patent native circumflex artery, we did not repeat left coronary or LIMA angiography but proceeded with the SVG intervention. Anticoagulation was successfully achieved with weight based Bivalirudin bolus and drip, and he was reloaded with 300 mg of Clopidogrel in the cath lab. Using a 6-French JR4 guide catheter and a 0.014” Asahi Prowater Flex (Abbot Co., Abbot Park, IL), the high-grade SVG lesion was crossed successfully. A 2.0 mm × 15 mm Sprinter balloon (Medtronic Co., Minneapolis, MN) was used for pre-dilation and was inflated to 10 atmospheres (ATM). ( Fig. 2 ). Attempts at advancing the stent past the lesion resulted in disengagement of the guide. A 2.5 mm × 15 mm cutting balloon was used at nominal pressure to further pre-dilate the lesion ( Fig. 3 ). Subsequently, we were able to perform optical coherence tomography (OCT), which showed significant in-stent restenosis in the ostium/proximal portion of the SVG with detailed visualizations of all 4 previous stent layers. ( Fig. 4 ). Next, a 3.0 mm × 28 mm Ion Paclitaxel drug-eluting stent (Boston Scientific Co., Natick, MA) was deployed at 16 ATM. The stent was post-dilated with a 3.25 mm × 21 mm Sprinter NC balloon at 18 ATM ( Fig. 5 ). A 3.0 mm × 8 mm Ion Paclitaxel drug-eluting stent was deployed at 18 ATM to treat the ostial lesion. Repeat OCT demonstrated excellent results with excellent visualization of all 5 stent layers. ( Fig. 6 ). The final angiogram showed great results ( Fig. 7 ). A 6-French Angioseal closure device was used to seal the arteriotomy site. The patient tolerated the procedure well and was discharged home the following day on triple antiplatelet therapy, with Cilastazol 100 mg twice a day being added to his regimen.
