A 58 years old man with background of hypertension was referred to our unit for activity limiting angina refractory to medical treatment. Coronary angiogram showed severe triple vessel disease with a distal right coronary artery (dRCA) total occlusion. Echocardiogram showed normal LVEF with no regional wall motion abnormality. He was counselled on revascularization for symptom control and opted for multivessel PCI over CABG as the definitive treatment.

A 7Fr AL 0.75 guiding catheter was engaged to RCA. dRCA CTO was successfully crossed with a Fielder XTR (Asahi) wire on Turnpike (Teleflex) microcatheter support, exchanged to a Runthrough NS (Terumo) wire and wired to the RPL. The CTO segment was predilated with 2mm semi-compliant ballon with restoration of TIMI 2 flow to RPL. PDA was wired and protected with another Runthrough NS. After vessel sizing with IVUS, a DynamX 2.5 x 38mm bioadaptor scaffold (Elixir) was implanted from dRCA to RPL, post dilated with 2.5mm non-compliant balloon. Proximal to distal RCA was further stented with 2 more DynamX scaffolds with excellent final angiographic results. IVUS also demonstrated good expansion and apposition of the bioadaptors.The patient was brought back for stage PCI of LCA 10 months after the index procedure. Restudy angiogram of RCA showed patent scaffolds with no in-scaffold restenosis. Quantitative coronary angiogram showed luminal gain with increase of minimal luminal dimension from 2.61 to 2.86mm. IVUS demonstrated significant positive remodeling of the entire RCA with evidence of late acquired stent malapposition (LASM) at the distal edge of previously implanted bioadaptors in RPL.Proximal RCA to RPL was further optimized with 4.5mm and 3.5mm NC balloons respectively with good biopadpator apposition on IVUS.Staged PCI of LAD and LCx were done uneventfully and the patient was scheduled for further restudy angiography in 8 month’s time.

To our best knowledge, this is the first reported case of biopadaptor usage in CTO intervention with a long-term angiographic and intracoronary imaging follow-up. Certain properties of the bioadaptor scaffolds, including the positive adaptive remodelling and restoration of pulsatility of the vessel, was well demonstrated despite in the complex CTO subset of lesion. In our case, the LASM in the follow-up procedure was treated with further balloon dilation. Further follow-up imaging studies are required to evaluate the behaviours of the bioadaptor in the longer term after such instrumentation.