Slides

Treatment of a Recurrent ISR lesion of pmRCA using Drug Eluting Stent

- Operator : Seung-Jung Park

Treatment of a Recurrent ISR lesion of pmRCA using Drug Eluting Stent
- Operator: Seung-Jung Park, MD
Case Presentation
A 74 year-old gentleman was admitted for PCI. Nine years ago, he underwent PCI at mLAD (Cypher 3.0x28mm) and pmRCA (Arthos 4.0x18mm and 3.5x38mm). Six months later, he experienced ISR at pmRCA, which was treated by POBA. And then, he was followed up regularly and last thallium scan showed normal perfusion. However, recent thallium scan showed reversible large perfusion defect at RCA territory and TMT showed significantly ST depression at second stage. His coronary risk factors were diabetes, hypertension, hyperlipidemia, and ex-smoker. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed mild to moderate LV systolic dysfunction (EF=46%) with RWMA of RCA territory.
Baseline coronary angiography
1. The left coronary angiogram showed patent previous stent at mLAD and collateral flow from LAD to RCA ( Movie 1, Movie 2).
2. The right coronary angiogram was diffuse in-stent narrowing up to 70% of pmRCA stent ( Movie 3, Movie 4).
Procedure
An 7 Fr JR 3.5 guiding catheter with side holes was engaged at the right coronary artery ostium through right femoral artery. And then, we inserted a 0.014 inch BMW wire into RCA. Predilatation was performed at pmRCA using a Black Hawk balloon 2.5x20mm (Figure 1). After predilatation, we deployed a Resolute Integrity stent 3.0x38mm at proximal to middle ISR lesion of RCA (Figure 2). Thereafter, post-stenting adjunctive balloon dilatation was done using a Dura Star balloon 3.5x15mm (Figure 3). Final angiogram showed that the procedure was successful ( Movie 5, Movie 6).

Comments

  • Mohammed Mohammed Al-Kebsi 2012-08-03 Very well done. i had same case in patient post CABG to LAD and Ramus + instent restenosis in the pmRCA which was treated in the same manner as you did. the problem that he still has on and off chest pain so i maximased his medical treatment. next step i will do strees for him. thanks. Dr. Mohammed - Sana'a- Yemen
  • Bing Liu 2012-08-04 Why was the procedure TFI, not TRI? And 6F GC was enough for the PCI, even 5F GC, based on the lesion characteristics！TRI via 6F or 5F was significantly safe for the pt. and the pt. should be more comfortable！The operater should regard pt. more completely,not only to accomplish a procedure by a easy way! It was not the first time to use a needless big size GC！
  • Mehdi Shahriayri Afshar 2012-08-10 Thanks for your nice PCI, May i ask you regarding drug eluting balloon (DEB ) for ISR and In case of recurrent ISR even by DES what can we do for fix an another time ISR ? Do we need to check the ISR PCI by IVUS ? What about Dual anti-platelet therapy duration after ISR PCI ? Good Luck
  • Achmad Fauzi Yahya 2012-08-14 I completely agree with Dr Liu Bing comment. Its better transradial approach and using a 5Fr GC would make patient more comfort. DEB is another alternative tool to handle the ISR.
  • prakash kumar hazra 2012-08-15 well done
  • Arash Gholoobi 2012-08-17 I would definitely post dilate the new stent with a 3.5 mm balloon at very high pressure.
  • khondker shaheed hussain 2012-08-17 well done.
  • Wenduo Zhang 2012-08-28 well done ,but i think you should take IVUS test ,to know what happened in the stent .
  • Shih-Hung Chan 2012-09-13 Regarding choice of large or small guiding catheter, I think we should consider multiple reasons. I think that whether one-step or two-step procedure is an important one. If you perform diagnostic coronary angiography in advance to PCI (two-step procedure), you can know what size of guiding catheter is enough; otherwise, you have better to choose large sheath and catheter to complete diagnostic angiography and PCI at one time (one-step procedure). I think to choose TRI or TFI is also related to the choice of one- or two-step procedure.

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