CASE20240812_003
The Never Ending Story
By Wittawat Wattanasiriporn
Presenter
Wittawat Wattanasiriporn
Authors
Wittawat Wattanasiriporn1
Affiliation
Rajavithi Hospital, College of Medicine, Rangsit University, Thailand1,
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CASE20240812_003
Complex PCI - In-Stent Restenosis
The Never Ending Story
Wittawat Wattanasiriporn1
Rajavithi Hospital, College of Medicine, Rangsit University, Thailand1,
Clinical Information
Relevant Clinical History and Physical Exam
Thai male 44 years, known hypertension, dyslipidemia, TVD c LM s/p PCI to multiple recurrent instent restenosis (PCI ISR RCA x 3 times (7DES + 1DCB), LM-LAD-LCx x 3 times (7DES)) presented with dyspnea on excertion 1 month. EKG showed Sinus rhythm, non specific ST-T change, Echocardiogram showed LVEF 43%, anterior wall hypokinesia, no significant valvular heart disease. Hb 13.5 g/dl Platelet 154,000 cell/cumm Cr 1.16 mg/dl GFR 76 ml/mi/1.73 m2 FBS 93 mg/dl HbA1C 5.9% LDL 62 mg/dl
Relevant Test Results Prior to Catheterization
EKG showed Sinus rhythm, non specific ST-T change, Echocardiogram showed LVEF 43%, anterior wall hypokinesia, no significant valvular heart disease. Hb 13.5 g/dl Platelet 154,000 cell/cumm Cr 1.16 mg/dl GFR 76 ml/mi/1.73 m2 FBS 93 mg/dl HbA1C 5.9% LDL 62 mg/dl
Relevant Catheterization Findings
CAG via Rt femoral approach with JL 6/4, JR 6/4 revealed Rt dominant LM: 50% Instent restenosis left main
Interventional Management
Procedural Step
What is the best strategy PCI? (1. DCB 2. Repeat DES 3. Rota stent + DES 4. CABG 5.Eximer laser 6. Medication 7. Other options?). PCI ISR LM-LAD-LCx (IVUS LM-LAD-LCx showed Neoatherosclerosis, 2.5 x 12 mm sc balloon predilated LM-pLCx upto 24 atm, 3.5 x 16 mm NC balloon predilate LM-LAD upto 26 atm, KBI with 3.5 x 16 mm NC balloon LM-LAD 18 atm vs 2.5 x 15 mm sc balloon LM-LCx upto 12 atm, POT with 4.0 x 12 mm NC balloon LM upto 24 atm, 4.0 x 13 mm NSE balloon LM upto 16 atm, Ischemic preconditioning strategy with sequential short balloon inflation time during LM PCI, 4.0 x 12 mm DCB inflated LM upto 14 atm). Final angiogram showed acceptable result.
Case Summary
Intravascular imaging is beneficial in determining the ISR mechanism, informing therapeutic strategy and confirming effective treatment of PCI. DCB is particularly useful for situations where the addition of another stent layer is undesirable, i.e., multiple previous stent layer. Ischemic preconditioning with sequential short balloon inflation time during LM PCI makes myocardium more adaptable to a subsequent ischemic insult.Performing PCI in young patients should be left distal landing zone in case of CABG in the future.