scholarly journals 712 In-stent restenosis: how optical coherence tomography can make the difference

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Sara Ricci ◽  
Gianfranco De Candia ◽  
Mauro Cadeddu ◽  
Giorgio Lai ◽  
Sara Secchi ◽  
...  
Keyword(s):  
Optical Coherence Tomography ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Stent Implantation ◽  
Proximal Segment ◽  
Optical Coherence ◽  
Stent Restenosis ◽  
Percutaneous Revascularization ◽  
The Right ◽  
In Stent Restenosis

Abstract Aims Patient male, 38 years old, affected by hypercholesterolaemia, carotid atherosclerosis, in 2014 NSTEMI (bivascular coronary artery disease treated by angioplasty and implantation of a medicated stent in the ostial and proximal tract of the right coronary artery). In September 2021 the patient went to the emergency room of our hospital for chest pain, that comes during physical exertion, with a spontaneous regression. We performed blood tests that showed phase rise of the Hs-TNI (>25 000 ng/dl). The ECG showed lateral sub-endocardial ischemia and the transthoracic echocardiogram a slight reduction in ejection fraction with hypochinesia of the inferior and inferior-lateral wall. After collegial discussion, it was decided to perform a coronary angiography. Methods and results The coronary angiography showed the left coronary artery free from stenosis, with a collateral circle towards the right coronary; the right coronary showed an ostial and proximal critical in-stent restenosis with patency of the stent in the middle segment, total occlusion of the distal segment. It was decided to treat the right coronary. A guide wire was pushed into to the right coronary with difficulty and, after recanalization of the vessel, an optical coherence tomography (OCT) was performed. The OCT pointed out a homogeneous widespread neointima into the stent and an extraluminal fibrous-calcified plaque in the ostial proximal segment, which caused likely the stent under-expansion and then the stent fracture. We proceeded with angioplasty and stent implantation of the distal lesion. Due to the mechanism underlying critical in-stent restenosis (fracture of the stent) of the ostial proximal segment, we first proceed with a pre-dilatation of the lesion and then with a stent in stent implantation. Post-dilatation with a non-compliant balloon at high atm. Eventually, we found out a detail not visible before due to the ostial stenosis: the protrusion of some millimeters of the previously implanted stent in the ascending aorta; this was the cause of the difficulty in advancing the angioplasty material throughout the procedure. As a result, we had no complications. Conclusions Intracoronary imaging has stronger evidences to guide the percutaneous revascularization, especially for in-stent restenosis. Evaluation by OCT can highlight the mechanism of in-stent restenosis (biological causes/mechanical causes) and consequently it can guide the most appropriate method to perform percutaneous revascularization.

scholarly journals 736 Hazy spots: through the eye of optical coherence tomography

2021 ◽  
Vol 23 (Supplement_G) ◽  
Author(s):  
Emiliano Bianchini ◽  
Rocco Vergallo ◽  
Angela Buonpane ◽  
Marco Lombardi ◽  
Alfredo Ricchiuto ◽  
...  
Keyword(s):  
Optical Coherence Tomography ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Stent Thrombosis ◽  
Anticoagulant Therapy ◽  
Stent Implantation ◽  
Optimization Technique ◽  
Optical Coherence ◽  
Coronary Syndrome ◽  
Acute Stent Thrombosis

Abstract Aims Acute stent thrombosis after coronary artery stent placement is a rare but serious complication in percutaneous coronary intervention (PCI). Stenting culprit lesions in acute coronary syndrome (ACS) has higher risk of acute stent thrombosis than stable coronary artery disease, and many local and systemic factors may contribute to increase this risk. Tissue protrusion (TP), and in particular, plaque prolapse after PCI can play a role in acute stent thrombosis, and intra-vessel imaging is the principal instrument to identify such underlying lumen alteration after stent implantation, and guide intervention. Methods and results We report the case of a 54-year-old man with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, obesity and no other relevant comorbidities in remote history, who underwent a coronary angiography for an unstable angina. A long, calcific sub-occlusion of the left anterior descending artery (LAD), which involved LAD-first diagonal branch (D1) bifurcation (Medina 1.1.1) and LAD-D2 bifurcation (Medina 1.1.0) was found. After deployment of two overlapping drug-eluting stents (DES), (ULTIMASTER TANSEI 3.0 × 38 mm and 3.0 × 21 mm) and struts apposition optimization with sequence of proximal optimization technique (POT) on D1 and D2, and a kissing balloon technique (KS) on LAD-D2 bifurcation, a ‘hazy’ in-stent image was detected right after the LAD-D2 bifurcation, suggesting an acute in-stent thrombosis, in absence of flow alteration (TIMI 3), symptoms or ECG modifications. Multiple thrombus-aspiration were made and resulted in abundant thrombus removal and improvement in the angiographic image, with persistent valid flow on every three vessels (TIMI 3). After 5 days of triple anticoagulant therapy with ticagrelor, cardioaspirin and UFH infusion, he underwent a new coronary angiography control. A similar ‘hazy’ image was detected right after LAD-D2 bifurcation within the LAD. An optical coherence tomography (OCT) pullback was made to assess the nature of the angiographic finding. OCT showed good struts apposition in almost every cross-sectional images, but an evident TP was detected right on the angiographic hazy spot. OCT allowed to evaluate the lipid-richness of the stented plaque and the nature of the TP, which was mixed with evident both white and red thrombus apposition (minimum luminal area measured 4.5 mm2). OCT guided a new PCI, with a stent-in-stent implantation on LAD. TP was absent on the post-PCI OCT run. Conclusions In this report, we showed the usefulness of OCT in revealing a potential high risk thrombogenic source. OCT not only characterized something that angiography alone couldn’t, but suggested the etiology of the amount of thrombus removed by the vessel during the first PCI. Indeed, despite an optimized cycle of anticoagulant therapy, OCT still revealed several mixed thrombus apposition on the TP, and this suggested its role in the acute stent thrombosis. OCT guided the choice to appose a new stent-in-stent to solve a potential thrombogenic source.

scholarly journals Severely Circumferentially Calcified Neointima as a New Cause of Undilatable In-Stent Restenosis

2018 ◽  
Vol 2018 ◽  
pp. 1-3
Author(s):  
Manabu Kashiwagi ◽  
Takashi Tanimoto ◽  
Hironori Kitabata
Keyword(s):  
Optical Coherence Tomography ◽  
Angina Pectoris ◽  
Coronary Angiography ◽  
Balloon Angioplasty ◽  
Balloon Dilatation ◽  
Optical Coherence ◽  
Stent Restenosis ◽  
Scoring Balloon ◽  
Recurrent Angina ◽  
In Stent Restenosis

A 74-year old man presented recurrent angina pectoris due to in-stent restenosis (ISR) with severely calcified neointima. In-stent neoatherosclerosis (NA) is associated with late stent failure, and NA with calcified neointima occurs in some cases. Because the presence of neointimal calcification could lead to underexpansion of newly implanted stent for ISR, a scoring balloon was selected for predilatation to obtain maximum extrusion of the neointimal plaque and subsequently, an everolimus-eluting stent was implanted. However, moderate stenosis remained on coronary angiography, and optical coherence tomography (OCT) revealed underexpansion of the newly implanted stent because an attempt at balloon dilatation of neointimal calcification failed. Although OCT can clearly discriminate stent struts from neointimal calcification, we did not perform OCT assessment between scoring balloon and stenting. It is highly recommended to confirm whether the lesion is adequately treated by balloon angioplasty before stenting in cases with calcified ISR.

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