Mr. Tseng

A 71-year-old male patient was admitted for frequent effort chest tightness and exaggerated exertional dyspnea for 2 months. That chest discomfort could be partially relieved by sublingual NTG. He underwent PCI with bare-metal stenting at both LCX and RCA 11 years ago. His coronary risk factors were hypertension, type 2 diabetes mellitus and dyslipidemia. No significant abnormality of physical exam. His electrocardiogram (ECG)demonstrated T wave inversion of lead II, III and aVF.

Echocardiography showed normal ejection fraction without regional wall motion abnormalities.
Tl-201 MPI: Severe ischemia at inferior wall of the left ventricle ( suggest hypoperfusion degree 65~70 % of RCA territories)

1. Left coronary angiogram showed significant stenosis from proximal to middle part of LAD. De novo tandem lesions at proximal and distal LCX. Both LAD and LCX gave collateral flow to RCA.
2. The right coronary angiogram showed in-stent chronic total occlusion (CTO) at mid RCA, diffusely extending to distal RCA trifurcation segment. The PDA received several collateral channels from LCX and septal artery of LAD. The J-CTO score was 3.
CAG- LAO Cran.wmv
CAG- Caud.wmv
CAG- AP Cran.wmv

A 6Fr sheath was inserted thorough left radial artery and, left coronary artery was engaged with a 6 Fr EBU 3.0 guiding catheter. 0.014-inch SION wire was inserted into LAD and another Gaia III wire loaded in a Corsair 135cmmicrocatheter was inserted into LCX (total in-stent restenosis). Pre-dilation performed with Euphora NC 3.0 x 15 mm balloon atLAD and a Sapphire NC 2.5 x 15 mm balloon at LCX (Kissing balloon technique). Owing to difficult dilatation of LCX ostium ISR, we used a 3.0x10 mm Cutting balloon. An Ultimaster 3.5x24 mm stent was properly deployed at LM, crossing to the proximal portion of LAD. A Sequent Please 2.75x25 mm drug-coated balloon was dilated at ISR lesion of LCX stent strut. Then final kissing balloon was performed with Euphora NC 3.5 x 15 mm balloon at LADand Euphora NC 3.0 x 15 mm balloon at LCX. Final angiogram and IVUS showed that the procedure was successful.
Distal RCA stenting.wmv
Reversed CART wire過.wmv
RCA final -LAT.wmv

1.    The rate of BMS-ISR is high, especially in multiple coronary risk factors group.2.    Drug-coated balloon should be considered whether in BMS-ISR or DES-ISR.3.    Cuttingballoon angioplasty was associated with some procedural advantages, such as use of fewer balloons, less requirement for additional stenting, and a lower incidence of balloon slippage.