The Modern PCI Toolkit for In-Stent Restenosis in Multiple layers of Stent
Presenter
Shruti Singh, MD, The University of Texas Health Science Center at Houston, Houston, TX
Shruti Singh, MD, The University of Texas Health Science Center at Houston, Houston, TX
Keywords: Complex and High-risk Coronary Intervention (CHIP), Drug-coated Balloon (DCB), Imaging & Physiology and Intravascular Lithotripsy (IVL)
Title
The Modern PCI Toolkit for In-Stent Restenosis in Multiple layers of Stent
Introduction
This is a case that demonstrates the use of drug coated balloon (DCB) for in-stent restenosis (ISR) to avoid addition of more layers of stents. More importantly, this case showcases use of various plaque modification tools to prepare and modify the lesion prior to the use of DCB.
Clinical Case
Patient is a 69-year-old man with a history of coronary artery disease, coronary artery bypass graft surgery (LIMA-LAD, RIMA-RCA, SVG-D1, SVG-OM), multiple PCIs (most recently PCI or the proximal RCA), ischemic cardiomyopathy, who presented with worsening exertional chest pain requiring sublingual nitroglycerin for relief. Cardiac PET revealed stress induced ischemia in the anterolateral, inferolateral, anteroseptal and apical distribution. Patient underwent coronary angiography which revealed moderate-severe ISR of the mid circumflex (3 layers of prior stents) and OM1 branch (1 layer of stent). FFR of the distal OM1 was 0.56, and IVUS showed under-expanded prior stents with areas of focal calcific stenosis. The lesion was modified with a 3.0 non-compliant balloon, followed by 3.0 Shockwave intravascular lithotripsy. A residual under-expanded lesion in the mid left circumflex was modified with a 3.0 Wolverine cutting balloon. Repeat FFR of the distal OM1 was 0.90. Repeat angioplasty with a 3.5 NC balloon was performed, and IVUS revealed adequately prepped lesion and improved expansion of the prior stents. Finally, a 3.5 x 30 mm Agent DCB was used to treat the distal OM1, and a 4.0 x 30 mm Agent DCB was used to treat the proximal left circumflex. Improved flow from OM1 collaterals to diagonal artery was noted.
Discussion
In-stent restenosis is common in patients with prior stents despite use of newer generation stents. Treatment of ISR involves first understanding the underlying causal mechanism using intravascular imaging. Depending on the mechanism of ISR, the treatment of can vary per patient. We show a case of ISR where successful treatment involved use of various different treatment modalities and tools to achieve the best results.