Abstract
The use of drug-coated balloons (DEB) for preventing restenosis is new and has received increasing interest. We present a patient who was admitted with recurrent angina with repeat interventions for restenosis events in a very short time using both BMS and DES. The restenosis was treated with kissing drug eluting balloons in the LAD–Diagonal bifurcation. More than one year after the DEB PCI, the patient is free from symptoms.
1
Introduction
Implanting a new drug-eluting stent inside the old stent is currently the most accepted approach for treating in-stent restenosis. But the rates of repeated restenosis for that treatment vary between 16% and 21% for treatment of restenosed bare-metal stents and are around 20% for the treatment of restenosed drug-eluting stents (DES) .
Drug eluting balloons (DEB) in which a drug such as paclitaxel is attached to the balloon and deployed in the lesion, may have potential benefits. Treating in-stent restenosis with a paclitaxel-coated balloon avoids a second layer of metal with a shortened dual antiplatelet therapy.
The benefit of treating in-stent restenosis with a DEB is sustained over the long-term, with low event rate as reports in the five-year results of the Treatment of In-Stent Restenosis by Paclitaxel-Coated Balloon Catheters (PACCOCATH ISR) . The PEPCAD 2 ISR study showed that a DEB is as good as paclitaxel-eluting stent for the treatment of in-stent restenosis in bare-metal stents . The ISAR-DESIRE 3 trial — a direct comparison of the DEB and a DES for the treatment of DES restenosis — has not been completed, but results are expected in the near future. We report a case in which 2 DEBs were used to treat a bifurcation restenosis of DES.
2
Case report
A 65 year old female with risk factors of diabetes, hypertension, hyperlipidemia and past smoker had non ST elevation anterior wall MI with pulmonary edema in February 2007. A single vessel disease in the proximal Left anterior descending artery (LAD) was diagnosed with 50% stenosis. The hypothesis of acute diastolic dysfunction due to hypertensive crisis was retained and the patient was discharged after a normal heart scintigraphy and optimization of her antihypertensive medication.
Four years later, in January 2011, the patient was admitted for the second time with chest pain and diffuse ST changes. Angiography revealed progression of the lesion in the proximal LAD. The narrowing was estimated at 80% involving the ostium of the 1st diagonal with Medina classification 1/1/1. A bare metal stent (BMS) 3 × 15 mm was inserted across the bifurcation without intervention to the diagonal.
Two months after discharge the patient was admitted again for typical exertion angina, CCS III. A new cath was performed showing diffuse in stent restenosis in the BMS with extent of the stenosis after the stent (type III of Mehran ISR classification) and a tighter stenosis also observed in the first diagonal (D1) ostium.
Two drug eluting stents (DES) (Endeavor Resolute 3 × 18 mm and Cypher 2.75 × 28 mm) were inserted in the LAD restenosis and a kissing balloon was performed in the LAD/D1 bifurcation with no residual stenosis in the LAD and a less than 30% stenosis in the ostium of the diagonal ( Fig. 1 ).
Three months after DES implantation, in June 2011, the patient was admitted again for typical chest pain with elevation of troponin, the patient underwent a new cath and a focal tight in-stent restenosis (type IC of Mehran ISR classification) was seen in the LAD just before the origin of the diagonal which was also involved with more than 90% stenosis ( Fig. 2 ).
At this point we wanted to avoid a third stent layer and therefore discussed with the patient the possibility of performing coronary artery bypass graft Vs DEB intervention.
Eventually the PCI option was preferred, several days later using the radial approach and a 7.5F sheathless 3.5-extra backup PCI was done. Predilatation was performed using kissing technique with a 3 × 15 mm balloon in the LAD and a 2 × 10 mm balloon in the diagonal. After obtaining a satisfying result we performed another kissing balloon technique using 2 Drug eluting balloons (Pantera Lux, Biotronik, Berlin Germany) 3 × 20 mm and 2.5 × 10 mm in the LAD and D1, respectively ( Fig. 3 ). A good final result was obtained with less than 30% residual stenosis in the diagonal and no angiographic residual stenosis in the LAD ( Fig. 4 ).
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