Rotational Atherectomy Followed by Drug-Coated Balloon Dilation for Left Main In-Stent Restenosis in the Setting of Acute Coronary Syndrome Complicated with Right Coronary Chronic Total Occlusion

Abstract

SummaryAn 83-year-old man presented with recurrent acute coronary syndrome (ACS) at the left main coronary artery (LMCA) complicated with ostial chronic total occlusion (CTO) in the right coronary artery (RCA) (RCA-CTO). At the first LMCA-ACS approximately 1 year earlier, he had undergone LMCA-crossover stenting with a biolimus-eluting stent in the presence of RCA-CTO. At the second LMCA-ACS, we angiographically confirmed severe in-stent restenosis in the distal LMCA, in addition to angled severe stenosis in the just proximal LCx, and performed primary PCI for the LMCA bifurcation lesion under intra-aortic balloon pumping support. Because of difficulty in crossing a guidewire through the just proximal LCx lesion, we first performed rotational atherectomy against the LMCA in-stent eccentric lesion. After successfully crossing the guidewire into the LCx, we added balloon dilation with kissing balloon inflation followed by alternate drug-coated balloon dilation. An eight-month follow-up coronary angiography revealed no further vessel narrowing in the LMCA bifurcation lesion.(Int Heart J 2017; 58: 806-811) Key words: Acute myocardial infarction, Intravascular Ultrasound, Percutaneous coronary intervention S ignificant unprotected left main coronary artery (LMCA) disease in the presence of chronic total occlusion (CTO) in the right coronary artery (RCA) (RCA-CTO) is a deteriorated condition with high morbidity and mortality, 1) and generally remains an absolute candidate for coronary artery bypass grafting (CABG) surgery even during new-generation drug-eluting stent (DES) era. Drug-coated balloon (DCB) has now played a central role in the treatment for in-stent restenosis (ISR) through inhibiting neointimal hyperplasia, 2,3) despite its little evidence for ISR in DES implanted in LMCA. [4][5][6] We describe our experience with an unusual critical case of recurrent acute coronary syndrome (ACS) due to ISR in LMCA complicated with ostial RCA-CTO, in which rotational atherectomy followed by DCB dilation against the LMCA bifurcation lesion could defer a further repeat intervention. Case ReportAn 83-year-old man with repeat ACS was admitted to our hospital due to general fatigue and chest discomfort for 24 hours. His coronary risk factors included hypertension and diabetes mellitus. He had experienced inferior myocardial infarction (MI) 35 years earlier, and undergone percutaneous coronary intervention (PCI) using a bare metal stent (BMS) (Multi-link Penta 2.5/18) for a posterolateral branch of the left circumflex coronary artery (LCx) 12 years before. He had suffered from LMCA-culprit ACS complicated with ostial RCA-CTO ( Figure 1A-C) and undergone LMCA-left anterior descending coronary artery (LAD) crossover stenting with a biolimus-eluting stent (Nobori 3.5/18) under intra-aortic balloon pumping (IABP) support 11 months earlier ( Figure 1D-F). Preprocedural intravascular ultrasound imaging (IVUS) depicted much concentric plaque with partial superficial calcification (Figure 2A), and final IVUS after the stent implantat...

Successful true cavity pathfinding with balloon assisted CTO with bifurcation lesions: Two case reports

“…[13] The use of drug-coated balloon to treat bifurcated lesions is a new therapeutic method. [14,15] This article deals with 2 patients who both suffered from CTO accompanied by bifurcation lesions. One patient's CTO was located in the left anterior descending artery (LAD) with anterior non-angle trifurcation lesions, while the other patient's CTO was in the posterior left artery (PLA) with posterior angle trifurcation lesions.…”

“…[ 13 ] The use of drug-coated balloon to treat bifurcated lesions is a new therapeutic method. [ 14 , 15 ]…”

Additional Use of a 6-Fr Intra-Aortic Balloon Pump on Extracorporeal Membrane Oxygenation Was Effective in a Patient with Cardiogenic Shock with Low Pulse Pressure

“…Although evidence from a large randomized controlled trial and a meta-analysis did not support the routine use of IABP in patients with cardiogenic shock, 3,4) IABP will continue to be used clinically in patients with cardiogenic shock or high-risk coronary artery diseases, including left main trunk (LMT) lesions and triple-vessel disease, because of a belief in a certain understanding of pathophysiology and anecdotal experience of improved clinical status. 1,5) Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide full cardiopulmonary support, resulting in sufficient organ perfusion. However, VA-ECMO also increases cardiac afterload and myocardial oxygen demand because oxygenated blood is returned to the femoral or axillary artery, which competes against cardiac antegrade flow.…”