Recurrent ISR Caused by Stent Underexpansion after Sirolimus-Eluting Stent Implantation for Treatment of In-Stent Restenosis

- Operator : Seong-Wook Park

Recurrent ISR Caused by Stent Underexpansion after Sirolimus-Eluting Stent Implantation for Treatment of In-Stent Restenosis

- Operator: Seong-Wook Park, MD, Seung-Whan Lee, MD
Case presentation
A 62 year-old man was admitted with resting chest pain for 3 months. He had been diagnosed as acute myocardial infarction 10 years ago, when received stenting at middle right coronary artery (RCA) in other hospital. At 2 years ago, he had undergone stenting with a 4.0 x 18mm and a 4.0 x 38mm bare-metal stents for the middle and distal RCA. His coronary risk factors were hypertension and smoking. Baseline ECG was normal. Echocardiography and Thallium scan did not reveal abnormal findings.
Baseline angiography and IVUS study
1. Right coronary angiogram showed a diffuse pattern of in-stent restenosis (ISR) in the middle RCA. Also, a new lesion in the proximal RCA was found. (Figure 1)
2. Left coronary angiogram showed newly developed diffuse narrowing at the proximal segment of the left anterior descending artery (LAD). (Figure 2)
A 7F sheath was inserted through the right femoral artery and the RCA was engaged with a 7F Judkins guiding catheter. A 0.014 inch Choice PT wire was placed into the RCA. At first, the ISR lesion of the middle RCA was predilated with a 3.5mm x 20mm Maverick balloon at 6atm and a 3.5mm x 23mm Cypher stent was deployed. (Figure 3) The proximal RCA lesion was also dilated with a 3.5mm x 20mm Maverick balloon at 12atm and a 3.5mm x 23 Cypher stent was deployed with overlapping.(Figure 4) And then additional high pressure ballooning was performed by using a 4.0mm x 20mm Stormer balloon at 18 atm in the proximal and middle stented segments.(Figure 5) Final right coronary angiogram showed good stent arrangement except mild underexpansion of the middle RCA stented segment(Figure 6, Figure 7). A minimum stent area (MSA) at the least area was 5.83mm2 by means of the IVUS evaluation at the index procedure. (Figure 8) For the proximal LAD lesion, we predilated it by using a 3.5mm x 25mm stent balloon at 8atm and delivered a 3.5mm x 32mm Taxus stent,(Figure 9) being contented with final angiogramí»s result.(Figure 10)
At 6 months after the index procedure, the follow-up coronary angiogram was achieved. The left coronary angiogram showed patent stented segment (Figure 11). But unfortunately, in the right coronary angiogram, we found a angiographic focal ISR at the stented segment of the middle RCA.(Figure 12) IVUS examination showed that the focal pattern ISR was caused by stent underexpansion, even though only a small amount of neointimal growth.(Figure 13) Because he had no subjective symptom, repeat intervention was not performed.


  • Marcelo Ribeiro 2004-09-05 From the first picture it seems that only proximal rca lesion was significant ; no matter how good DES stents might appear, it is still early days in the assessment of this technology ,so I would be more conservative .

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