Slides
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) |
Procedures |
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. (![]() |
Follow-up |
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.(![]() |
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