Recurrent In-Stent Restenosis With Total Occlusion Remedied With Drug-Eluting Balloon Angioplasty A Case Report

Abstract

SummaryWe report a 69 year old female who presented with chest pain to the Emergency Department of the National Heart Institute Malaysia. Her history revealed that she had had 2 separate episodes of chest pain beginning in 2002, resulting in total occlusion of her mid left anterior descending artery (LAD) requiring percutaneous coronary intervention and stenting on both occasions. Cine angiogram on her current admission revealed recurrent target lesion in-stent restenosis with total occlusion of the distal LAD. Intravascular ultrasound revealed multilayered suboptimally deployed stents in the LAD. Successive drug-eluting balloon deployments resulted in sustained patency of the LAD after 1 year. (Int Heart J 2011; 52: 61-63) Key words: In-stent restenosis, Angioplasty, Drug-eluting balloon S tents are a crucial and indispensible tool for coronary interventionists. Their efficacy, however, has been limited by the development of in-stent restenosis (ISR) secondary to neointimal proliferation. 1) Drug-eluting stents (DES) have, in the past decade, markedly reduced the incidence of binary restenosis and repeat coronary revascularization.2) However, there is limited data on optimal management of DES restenosis. Some studies have shown similar benefits between repeat DES stenting and conventional balloon angioplasty, whereas others have shown clear benefit for repeat DES stenting.2-4) Percutaneous coronary balloon angioplasty has been largely superseded by repeat DES stenting or the 'sandwich stenting' technique, which is steadily gaining prominence.5) We report a case of recalcitrant target lesion ISR which was successfully treated with drug-eluting balloon deployment. A repeat coronary angiogram 1 year later revealed sustained target lesion patency and the patient remains symptom free. Case ReportA 69-year-old female with a history of diabetes, hypertension, and hyperlipidemia since 1990 and on regular medication, has had recurrent episodes of stable angina since 1997. She was put on aspirin but was never investigated for coronary artery disease due to patient refusal to consent for further evaluation or intervention.In 2002, she had a severe episode of chest pain which necessitated admission to a peripheral hospital from where she was eventually referred to the National Heart Institute in Kuala Lumpur. Her coronary angiogram then revealed a total occlusion of the left anterior descending artery (LAD) which was remedied with two overlapping Cypher DES extending from the mid to distal LAD (2.5 × 33 mm and 2.75 × 33 mm, Cypher TM sirolimus-eluting stent; Cordis Corp., Miami, FL) (Figures 1A-F). She was discharged with dual antiplatelet therapy.In 2003, she had recurrent symptoms and a repeat angiogram showed ISR with total occlusion of the mid LAD. Percutaneous coronary intervention (PCI) was attempted with a cutting balloon (3.0 × 15 mm, 3.5 × 15 mm and 4.0 × 10 mm; InterVentional Technologies Inc., San Diego, CA). This was followed by two bare-metal stents (BMS), Multi-Link Penta The PCI was complicated by perfor...

Use of drug-eluting balloon coronary intervention prior to living donor kidney transplantation

“…Thus, preoperative PTCA without stenting seems to be a good “bridging strategy” for patients with intermediate urgency of the planned operation. A recently increasingly used alternative is an intervention with drug eluting balloons [8–10]. Several clinical investigations underline the meaning of drug-eluting balloons in the treatment of instent stenosis [19–21].…”

“…At the same time, more and more drug-eluting stents are used by interventional cardiologists. To minimise this problem a bipartite intervention using a drug-eluting balloon is a possible alternative [8–10]. Until now, no investigations or case reports are published examining the use of drug-eluting balloons in a perioperative setting.…”