Case Presentation: Shockingly Unshockable: Undilatable Lesion in Severe In-Stent Restenosis
Maximillian Bourdillon, MD, The University of Texas Health Science Center at Houston, Houston, TX
Maximillian Bourdillon, MD, The University of Texas Health Science Center at Houston, Houston, TX
Keywords: Acute Coronary Syndromes (ACS), Complex and High-risk Coronary Intervention (CHIP), Coronary and Intravascular Lithotripsy (IVL)
Title:
Shockingly Unshockable! Undilatable Lesion in Severe In-Stent Restenosis
Introduction:
The emergence of novel calcium modification techniques such as intravascular lithotripsy (IVL) has enhanced approaches to lesion preparation. This case of recalcitrantly calcific severe in-stent restenosis (ISR) highlights the need to be facile across plaque modification modalities following inadequate vessel preparation with IVL.
Clinical Case:
An 84-year-old male with history of diabetes, cardiomyopathy with mid-range ejection fraction, prior PCI of the left anterior descending (LAD) and RCA presented with non-ST segment elevation myocardial infarction (NSTEMI) and acute heart failure. Attempts at drug eluting stent (DES) implantation to severe RCA ISR was unsuccessful at another center. Following that hospitalization for NSTEMI, an interval outpatient rest/stress positron emission tomography perfusion scan revealed moderate-sized partially reversible inferior perfusion defect with border-zone ischemia. On the present admission, his labs were notable for rising high-sensitivity troponin-I 500 to 8,168 pg/ml. Diagnostic coronary angiography revealed moderate diffuse ISR of the RCA, with a heavily calcified high grade thrombotic appearing lesion of the mid-distal RCA ISR. Left coronary angiography revealed patent LAD stents with moderate ISR, stable from prior angiogram. The RCA was felt to be the culprit lesion for the patient’s presentation. The lesion was crossed with a workhorse wire and serial high pressure noncompliant balloon inflations were performed with minimal luminal gain. The vessel was subsequently treated with 2.5 mm and 3.0 mm intravascular lithotripsy (IVL) balloons; the recalcitrant calcium did not yield. With additional guide extender support, prolonged super high pressure (30 atms) cutting balloon angioplasty achieved adequate lesion preparation. Two overlapping DES were subsequently implanted in the mid to distal RCA.
Discussion:
Adequate lesion preparation is essential, highlighted by this case of severe recalcitrantly calcified ISR. While emerging technologies such as IVL have enhanced approaches to treat calcified plaques, remaining facile in all calcium modifying techniques is imperative. In particular, the superior maximal tensile strength of cutting balloon angioplasty in comparison to noncompliant balloon angioplasty and even IVL is underscored in this complex case.