Heavily Calcified Coronary Lesions Preclude Strut Apposition Despite High Pressure Balloon Dilatation and Rotational Atherectomy In-Vivo Demonstration With Optical Coherence Tomography

Abstract

rossing the lesion, initial dilatation by balloons and final stent expansion can present a challenge to the operator's skill and experience with heavily calcified lesions (HCL), because of the highly angulated lumen of these lesions and their resistance to expansion. 1,2 If balloons cannot cross or be expanded and the poorly steerable, thin, uncoated Rotablator ® wire (Boston Scientific, Natick, MA, USA) can be advanced, rotational atherectomy can result in favorable lesion modification that facilitates lesion dilatation and stent expansion. 3,4 Other methods of lesion preparation (eg, cutting balloon, high pressure pre-and post-dilatation) have been advocated for obtaining optimal stent expansion and apposition. Based on the examination of 3 representative cases with optical coherence tomography (OCT), we explain why optimal strut apposition remains an elusive target in the presence of heavy eccentric calcified plaques. Case Reports Case 1A 66-year-old male admitted with typical angina pectoris on a background of hypertension, hyperlipidemia and previous myocardial infarction underwent coronary angiography, which demonstrated long segments of heavily calcified severe stenoses in the mid left circumflex artery (Fig 1). The Circulation Journal Vol.72, January 2008lesions were sequentially dilated with 1.5 and 2.0 mm noncompliant balloons up to 16 atm. Three sirolimus-eluting stents (SES, Cypher Select™, Cordis, Johnson and Johnson Co, Miami Lake, FL, US), 2.5×18, 3.0×13 and 3.0×23 mm, were implanted in an overlapping fashion and post-dilated with a non-compliant 3.0 mm balloon to 22 atm. Although the angiogram showed optimal lesion dilatation with only minimal lumen haziness (Fig 1C), OCT (LightLab Imaging Inc, Westford, MA, USA) revealed suboptimal stent expansion and poor stent strut apposition. 5 Despite multiple high-pressure dilatations, optimal circumferential expansion could not be achieved (Fig 2A). The irregular contours of the stent struts maintained a circular geometry and were unable to fully conform to the slit-like lumen induced by the severe calcification. Although circumferential expansion showed greater minimal lumen diameter compared with elliptic expansion (3.17×2.86 mm vs 3.33×1.97 mm), some struts still remained malapposed to the intima at the intimal tear between the superficial eccentric calcification and non-calcified intima (Fig 2). Although the stent expansion was acceptable, matching the distal reference lumen area, the irregularity of the lumen contours because of protruding eccentric calcification precluded strut apposition. We administered IIb/IIIa inhibitors and recommended long-term dual anti-platelet treatment. Follow-up at 4 months was uneventful. Case 2A 71-year-old male admitted with angina pectoris on a background of hypertension, hyperlipidemia and previous myocardial infarction underwent coronary angiography, which demonstrated HCL in the mid right coronary artery. As no balloon could cross the stenosis, a Rotablator wire was inserted and a 1.5-mm burr was used, followed by ...

Predictors and Long‐Term Clinical Impact of Acute Stent Malapposition: An Assessment of Dual Antiplatelet Therapy With Drug‐Eluting Stents (ADAPT‐DES) Intravascular Ultrasound Substudy

“…Some retrospective studies have related ASM to stent thrombosis, but most of these studies enrolled only patients with stent thrombosis and in small numbers 24, 25, 26, 27. Conversely, Guo et al1 reported that 40% of ASM resolved at 13‐month follow‐up because of negative remodeling; this was similar in paclitaxel‐eluting stents and BMS with no deaths or stent thromboses related to the presence of stent malapposition at 1‐year follow‐up in either group.…”

Long-Term Follow-up of Neointimal Coverage of Sirolimus-Eluting Stents

“…Intravascular optical coherence tomography (OCT) is a newly developed intravascular imaging modality with a maximal spatial resolution of 10 μm, [13][14][15] which is approximately 10-fold higher than that of IVUS. The aim of the present study was to use intravascular OCT to analyze the time course of neointimal coverage of SES in the chronic phase, and to identify the predictive factors influencing delayed neointimal coverage of stent struts.…”

Clinical Outcomes of Sirolimus-Eluting Stenting After Rotational Atherectomy

“…21 The recent imaging modality of optical coherence tomography has detected stent strut malapposition, which is a potential risk factor for restenosis or thrombosis because of the increased activity of fibrin and platelets, 22 after treatment of heavily calcified lesions, despite the use of high-pressure dilatation or ROTA. 23 Changes in strategy from the BMS to the SES era, including smaller diameter and longer stents, and smaller burr size in the ROTA-SES group, may be related to the poor outcome after ROTA-SES in the dialysis patients.…”

“…24,25 Heavily calcified lesions sometimes lead to suboptimal expansion and strut malapposition, which are potential risk factors for stent thrombosis after DES use, 13,26 even after ROTA and high-pressure balloon dilatation. 23 Patients with calcified lesions that require ROTA, but who may not have been adequately treated with angioplasty, have a potentially high risk of stent thrombosis, so careful long-term monitoring is required.…”