Lots of interesting abstracts and cases were submitted for TCTAP 2025. Below are the accepted ones after a thorough review by our official reviewers. Don’t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!

• Abstract
• Case

TCTAP C-104

A Clinical Case of Six PCI Procedures for Repeated In-Stent Restenosis in the Left Main Ostium

By Naoki Shibata, Hoshito Karasawa, Yasuhiro Morita, Itsuro Morishima

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Presenter

Naoki Shibata

Authors

Naoki Shibata¹, Hoshito Karasawa¹, Yasuhiro Morita¹, Itsuro Morishima¹

Affiliation

Ogaki Municipal Hospital, Japan¹,

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TCTAP C-104

Coronary - Complex PCI - In-Stent Restenosis

A Clinical Case of Six PCI Procedures for Repeated In-Stent Restenosis in the Left Main Ostium

Naoki Shibata¹, Hoshito Karasawa¹, Yasuhiro Morita¹, Itsuro Morishima¹

Ogaki Municipal Hospital, Japan¹,

Clinical Information

Patient initials or Identifier Number

Relevant Clinical History and Physical Exam

A man in his 70s underwent coronary artery bypass grafting with a left internal thoracic artery graft to the LAD 25 years ago. Five years ago, he received a DES from the LCX to the LMT ostium for angina. He experienced three episodes of ISR treated with POBA and DCB. Recently, effort angina appeared again. 

Relevant Test Results Prior to Catheterization

The patient has well-controlled diabetes and no renal dysfunction. However, the LVEF has decreased to 30%, and stress scintigraphy revealed ischemia in the lateral wall.

Relevant Catheterization Findings

The right coronary artery shows no significant stenosis, and the LITA-LAD graft remains patent. However, the LMT is occluded from its ostium.

Interventional Management

Procedural Step

During the fourth intervention, total in-stent occlusion was identified at the LMT ostium. Using a Gaia Next 2 wire, the lesion was crossed successfully. While a semicompliant balloon could pass, a cutting balloon could not, and IVUS revealed stent under-expansion as the cause. Rotational atherectomy with a 1.75 mm burr was performed, followed by POBA with a 3 mm compliant balloon, and the procedure was finalized with drug-coated balloon DCB therapy. Six months later, a fifth in-stent occlusion occurred. The lesion was crossed with a Gaia Next 4 wire, and this time, distal lesion preparation was prioritized. DCB was used to dilate the lesion, but proximal stenosis required a 2.0 mm burr for ablation. The larger burr could not cross the occlusion, so proximal ablation was completed with the 2.0 mm burr, and distal ablation with a 1.75 mm burr. Significant slow flow was observed, and the procedure concluded with DCB therapy. At the sixth intervention, after deploying DES at the distal lesion, IVUS showed plaque-dominated stenosis at the LMT lesion, treated with POBA to obtain a sufficient lumen, followed by successful implantation of a new DES with optimal expansion. No further occlusions have been observed since.

Case Summary

This case highlights the challenges of treating repeated in-stent occlusion in the LMT ostium, which required careful selection of guiding catheters, appropriate rotational atherectomy burr sizes, and effective management of slow flow phenomena. We report this case to share our experience in managing this complex condition and overcoming its associated procedural difficulties.