Abstract
A 56-year-old male with a past history of coronary artery bypass graft surgery underwent stent implantation for a severe proximal left subclavian artery stenosis. Recurrent in-stent restenosis (ISR) resulted in the coronary subclavian steal syndrome (CSSS), with angina due to compromised blood flow in the left internal mammary artery/radial composite bypass graft. This was treated with cutting balloon predilatation followed by paclitaxel-coated balloon (PCB) dilatation, with an excellent angiographic result. At 10 months of follow-up, blood pressure in both arms was equal, and the patient remained symptom free. To our knowledge, this is the first report of successful treatment of subclavian ISR causing CSSS with a PCB.
1
Introduction
The introduction of first bare metal stents (BMSs) then drug eluting stents (DESs) has dramatically decreased the incidence of restenosis during percutaneous coronary intervention. In-stent restenosis (ISR) does however still occur even following DES implantation. This can be treated in a number of different ways including brachytherapy and repeat stenting using a DES with a different drug. There is increasing interest in the use of new drug-eluting balloons that release drug into the arterial wall during brief contact at a dose that is sufficient to inhibit neointimal proliferation for a prolonged period of time but without the ongoing potentially inflammatory stimulus of a stent.
Here we present a case combining the use of a cutting balloon to debulk the overgrown neointima followed by a drug-eluting balloon to treat recurrent subclavian ISR.
2
Description of case
A 56-year-old male with a history of peripheral vascular disease and coronary artery bypass graft (CABG) surgery 8 years previously presented with a non ST elevation acute coronary syndrome (NSTE-ACS) following 4 months of stable anginal symptoms. His electrocardiogram showed inferolateral T-wave inversion, and his troponin I was 0.26. Coronary angiography showed an occluded left anterior descending coronary artery (LAD), occluded right coronary artery (RCA) and a small heavily diseased nondominant circumflex artery (Cx). The left subclavian artery was severely stenosed proximal to the origin of the left internal mammary artery (LIMA) with a resting pressure gradient of 40 mmHg. His CABG had involved the LIMA to the LAD and a composite radial graft from the LIMA to the RCA–posterior descending artery. The LIMA and composite radial graft were widely patent with good run-off providing the majority of the myocardial blood supply. The subclavian stenosis was felt to be the culprit and was treated with a 7.0×24-mm Palmaz-Genesis bare metal stent (Cordis) ( Fig. 1 ).
He represented 3 months later with angina provoked by exertion or combing his hair with his left hand. Left arm blood pressure was undetectable. Repeat angiography showed severe restenosis within the subclavian stent ( Fig. 2 ). This was dilated with a conventional balloon providing good initial symptomatic benefit, but within 3 months, his angina returned and severe diffuse ISR was found again at angiography. Intravascular ultrasound (Boston Scientific Atlantis) showed no evidence of a mechanical problem with the stent, and the restenosis was treated with a 7-mm cutting balloon (Boston Scientific) ( Fig. 3 ) followed by a 7-mm×60-mm Freeway paclitaxel-coated balloon (PCB) (Eurocor) ( Fig. 4 ) inflated for 60 s. An excellent angiographic result was achieved ( Fig. 5 ) with restoration of left arm blood pressure (undetectable preprocedure) and resolution of symptoms. At 10 months, the patient remained symptom free with equal blood pressures in both arms.
2
Description of case
A 56-year-old male with a history of peripheral vascular disease and coronary artery bypass graft (CABG) surgery 8 years previously presented with a non ST elevation acute coronary syndrome (NSTE-ACS) following 4 months of stable anginal symptoms. His electrocardiogram showed inferolateral T-wave inversion, and his troponin I was 0.26. Coronary angiography showed an occluded left anterior descending coronary artery (LAD), occluded right coronary artery (RCA) and a small heavily diseased nondominant circumflex artery (Cx). The left subclavian artery was severely stenosed proximal to the origin of the left internal mammary artery (LIMA) with a resting pressure gradient of 40 mmHg. His CABG had involved the LIMA to the LAD and a composite radial graft from the LIMA to the RCA–posterior descending artery. The LIMA and composite radial graft were widely patent with good run-off providing the majority of the myocardial blood supply. The subclavian stenosis was felt to be the culprit and was treated with a 7.0×24-mm Palmaz-Genesis bare metal stent (Cordis) ( Fig. 1 ).
