In-stent Restenosis in Ostial LAD Treated with a TAXUS Stent

- Operator : Charles Chan

In-stent Restenosis in Ostial LAD Treated with a TAXUS Stent

- Operator : Charles Chan, MD, PhD, Singapore

Case Presentation
The patient was 43 year-old male admitted with exertional chest pain on August 2002. His coronary risk factors were hypertension and hyperlipidemia. His baseline coronary angiogram showed diffuse triple vessel disease. Therefore, he underwent multivessel PCI with a 3.0 20 mm ExpressTM stent for the proximal LAD lesion, a 3.0 12 mm ExpressTM stent for the LCX lesion, and a 3.0 8 mm ExpressTM stent for the proximal RCA lesion. However, he admitted again on January 2003 with chest pain.
Baseline Coronary Angiography
1. Left coronary angiogram showed diffuse in-stent restenosis in the proximal LAD and the narrowing was extended to distal LMCA (Figure 1, Figure 2).

2. The stent in RCA was patent.
Procedure
A 7 Fr sheath was inserted through right femoral artery and the left coronary was engaged with a 7 F XB catheter. Left main to LAD was wired with a 0.014 inch conventional wire. Although the left coronary angiogram showed intermediate lesion in distal LMCA, we decided to treat only the ostial LAD ISR lesion for prevention of ostial LCX narrowing after stenting. After cutting balloon angioplasty with a 2.5 10 mm cutting balloon, a 2.5 24 mm TAXUSTM stent was implanted for ostial LAD ISR (Figure 3). Final angiogram revealed very good result without a significant stent jail of LCX (Figure 4, Figure 5).
Unfortunately, he was readmitted with an anterior MI 5 days later. Coronary angiogram showed total occlusion in ostial LAD stent due to stent thrombosis (Figure 6). The lesion was treated with a 3.0 15 mm Quantum balloon while intravenous integrilin was infused (Figure 7). Final angiogram showed successful result with TIMI 3 flow (Figure 8).

Comments

  • Marcelo Ribeiro 2003-06-20 Sometimes we have to back up a litte;as a matter of fact, actually,if you are intended to do a percutaneous intervention but the case precludes an optimal(percutaneous) approach because of excessive risks,the best thingh to do is to abort the procedure.If we look to the angiogram at the time of restenosis,we could easily see that the chosen aproach would not completely resolve the ischemic territory of this patients heart.So,at present time,this patient still needs a surgical treatment.
  • Charles Chan 2003-06-20 I agree that surgery was an option. However, this is a young patient and only the LAD has restenosed and the RCA and LCX have remained patent. The main point of discussion is how to treat an ostial LAD lesion including in-stent restenosis. I think with DES, we can safely stent the distal left main so as not to miss the ostium of LAD.
  • Ahtisham Shakoor 2003-06-25 In an ostial LAD if you are thinking of using 2.5 stent then you must prove it with IVUS that infact you really need 2.5 stent.One should try to avoid placing 2.5 stents in prox LAD.Tough case which ended with excellent result.
  • Seung-Jung Park 2003-06-25 I agree Dr.shakoor's opinion. We may consider that the stent thrombosis would be related with the under-expansion of stent.
  • Jin Bae Lee 2003-06-27
  • Jae Yoon Go 2003-07-03
  • Charles Chan 2003-07-04 I agree that 2.5 mm Taxus stent is undersized initially. However, I am not sure whether bigger is better in DES. The choice of stent size is also influenced by the diffuse intimal proliferation giving a false impression the vessel size is smaller.
  • Zhonghan Ni 2007-11-05 Dr Chen:thank you for presenting such a failure case,we always learn much from MACE,if available can you give follow-up result recently(2007).

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