Slides
Very Long In-Stent Restenosis Treated by Cutting Balloon Angioplasty and Beta-Radiation Therapy using 188Re Filled Balloon
- Operator : Alan C. Yeung
Very Long In-Stent Restenosis Treated by Cutting Balloon Angioplasty and Beta-Radiation Therapy using 188Re Filled Balloon |
- Operator : Alan C. Yeung, MD |
Case Presentation |
The patient was a 45 year-old man. In December 2002, he had a myocardial infarction and was treated with a 3.5 x 30 mm S7 stent and a 3.0 x 30 mm S7 stent with minimal overlap in mid to distal RCA. His coronary risk factor was hypertension. Baseline ECG revealed normal. Treadmill test showed positive results at stage 3. Echocardiography showed good LV function. |
Baseline Coronary Angiography |
1. Normal left coronary artery 2. Rright coronary angiogram showed diffuse moderate to severe in-stent restenosis from mid RCA to distal RCA, not involving branching point (Figure 1). |
Intravascular ultrasound |
IVUS image showed tight stenosis with neointima from middle RCA to distal RCA (Figure 2). Stent lumen CSA was 6.51mm2 |
Procedure |
A 7F Judkins guiding catheter was engaged at the ostium of RCA. A Floppy guidewire was placed from RCA to the posterior descending artery. The RCA lesion was dilated 4 times using a 3.0 x 10mm cutting balloon (Figure 3, Figure 4). After cutting balloon angioplasty, coronary angiogram showed successful treatment of the in-stent restenotic (ISR) lesion (Figure 5). After then, the radioactive source (a 3.0 x 40mm balloon filled with liquid 188-Re) was inserted into the RCA ISR lesion and inflated to 6 atm (Figure 6). However, the ISR lesion was not radiated with a single long balloon dilatation. Therefore, manual stepping of radiation therapy was done with minimal overlapping (Figure 7). The dwell time lasted 267 seconds that delivered 20Gy to a depth of 1.0mm from the balloon-neointima interface. The post-intervention angiogram showed severe narrowing probably due to plaque shift at posterolateral (PL) branch (Figure 8). Thus balloon angioplasty with a 2.5 x 20 mm balloon at 8 atm was performed (Figure 9). Following angiogram revealed dissection confined to PL branch (Figure 10). And then the dissection was treated with a 2.5 x 18 mm BX stent at 8 atm. Final angiogram showed a good result without significant residual narrowing or dissection (Figure 11). |
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