The application of a drug-coated balloon in revascularization of the right coronary artery with in-stent restenosis and chronic total occlusion
Presenter
Marika Harada, MD, Baylor Scott & White The Heart Hospital - Plano, Plano, TX
Marika Harada, MD, Baylor Scott & White The Heart Hospital - Plano, Plano, TX, Karthik Subramanian Anand, MD, Texas Cardiovascular Institute, Fort Worth, TX and Karim Al-Azizi, M.D., FSCAI, Baylor Scott & White Health, Frisco, TX
Title
The application of a drug-coated balloon in revascularization of the right coronary artery with in-stent restenosis and chronic total occlusion
Introduction
A drug-coated balloon (DCB) is commonly used in the intervention of peripheral vascular disease. The application of DCB in the coronary arteries with in-stent restenosis (ISR) and chronic total occlusion remains rare. Herein, we present a case of DCB in the chronic total occlusion (CTO) related to ISR.
Clinical Case
A 69-year-old male with a mycotic aneurysm status post femoral-popliteal bypass on the right common femoral artery and diabetes presented with angina on two maximally tolerated anti-anginal medications. His diagnostic coronary angiography revealed CTO of the proximal to middle right coronary artery (RCA) secondary to ISR of previous stents. Given his persistent angina, revascularization of the CTO was performed. After a few guide wire escalations, the RCA was visualized with Refinity Rotational intravascular ultrasound (IVUS), revealing well-expanded and apposed previous stents with luminal neo-intimal hyperplasia. Diffuse fibrocalcific stenosis was noted distally. The laser atherectomy (1.4 mm, 3 passes, 54 pulses), scoring balloon angioplasty with Angiosculpt (3.5 X 10 mm), and multiple balloon angioplasties were performed. Because of well-expanded previous stents, the decision was to only treat the distal RCA with a drug-eluting stent (Onyx Frontier 3.5 X 22 mm). DCB (Ranger 4.0 X 60 mm) was then inflated inside previous stents. There was TIMI 3 flow with 0% residual stenosis post-intervention.
Discussion
The new procedural techniques and the use of IVUS have improved the complication rate of CTO intervention to less than 3%. However, the PCI of CTO can be challenging to achieve successful revascularization due to the risk of stent under-expansion in heavily calcified lesions. DCB allows immediate delivery of anti-proliferative agents directly into the targeted artery. Paclitaxel, which inhibits cell proliferation and migration, reduces neo-intimal hyperplasia of the vascular tissue. Efficacious drug delivery leads to reduced occurrence of restenosis in these vessels. DCB does not require the placement of foreign bodies into the targeted vessels, which can lead to less occurrence of ISR when compared to the rate of restenosis in conventional stent placement. In summary, the application of DCB in CTO remains rare but its method of direct drug delivery is promising and effective to achieve a reduction in restenosis. In the future, further studies are warranted to support the efficacy of DCB in CTO intervention.