Abstract
The optimal management of instent restenosis has yet to be fully clarified. Drug eluting balloons are a popular strategy, but a new stent is preferred when dilatation gives a suboptimal result because of insufficient extrusion of neointimal tissue. There is concern for adding multiple permanent metallic layers to the vessel wall, especially in small vessels. The use of bioabsorbable vascular scaffolds appears an appealing alternative strategy, since it scaffolds the neointimal tissue without further adding metal struts to the vessel wall.
1
Introduction
Drug eluting stents (DES) and especially second generation DES reduce in-stent restenosis, but the expansion of interventions towards more complex lesions may mean that the absolute number of restenoses remain high. Moreover, late neointimal growth and neoatherosclerosis may lead to a higher frequency of reinterventions in the long-term. The optimal management of instent restenosis has yet to be fully clarified. Drug eluting balloons are a popular strategy, but a new stent is preferred when dilatation gives a suboptimal result because of insufficient extrusion of neointimal tissue. There is concern for adding multiple permanent metallic layers to the vessel wall, especially in small vessels. The use of bioabsorbable vascular scaffolds (BVS) appears an appealing alternative strategy, since it scaffolds the neointimal tissue without further adding metal struts to the vessel wall. We describe two cases of in-stent restenosis where BVS achieved an excellent angiographic result after careful preparation of the lesion with high pressure balloon and cutting balloon dilatation guided by serial optical coherence tomography.
2
Case 1
A 53-year-old man with hypertension and diabetes developed recurrent chest pain 3 years after 3-vessel percutaneous coronary intervention (PCI), including recanalization of a chronic total occlusion of the left anterior descending coronary artery (LAD). Repeat angiography showed patent right coronary and left circumflex (LCx) stents, with 70% LAD in-stent restenosis ( Fig. 1 A–C ). After adequate lesion preparation with 2.0 non-compliant and 3.5 × 10 mm cutting balloon, a 3.5 × 18 mm bioabsorbable vascular scaffold (BVS, Abbott Vascular, USA) was deployed at 14 atm and post-dilated with a 3.5 mm non compliant balloon at 16 atms. Control OCT showed good strut apposition with a minimal lumen area of 7.19 mm 2 ( Fig. 1 D–E). Patient was discharged on dual antiplatelet therapy. Patient remained symptom free in 1 year follow-up.
2
Case 1
A 53-year-old man with hypertension and diabetes developed recurrent chest pain 3 years after 3-vessel percutaneous coronary intervention (PCI), including recanalization of a chronic total occlusion of the left anterior descending coronary artery (LAD). Repeat angiography showed patent right coronary and left circumflex (LCx) stents, with 70% LAD in-stent restenosis ( Fig. 1 A–C ). After adequate lesion preparation with 2.0 non-compliant and 3.5 × 10 mm cutting balloon, a 3.5 × 18 mm bioabsorbable vascular scaffold (BVS, Abbott Vascular, USA) was deployed at 14 atm and post-dilated with a 3.5 mm non compliant balloon at 16 atms. Control OCT showed good strut apposition with a minimal lumen area of 7.19 mm 2 ( Fig. 1 D–E). Patient was discharged on dual antiplatelet therapy. Patient remained symptom free in 1 year follow-up.
