E-Science Station

case3 Niguarda

Female 63 years oldTabagism, hypertension; dyslipidemiaJun 2018 Chronic total occlusion anterograde recanalization of RCA with 2 everolimus eluting stent (Synergy 2.5/48 e Xience 3/38) for angina with normal left ventricle ejection fraction. Sep 2019 Recurrent angina. In-stent total occlusion.
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At IVUS the previous implanted stent was undersized with in-stent proliferation at mid RCA an at the ostium the protruding struts were non coaxially cannulated. Reference vessel diameter at mid RCA3.0-3.5, at proximal RCA 4.0-4.5 mm.

The restenotic lesion was dilated with balloon (Tazuna 2.0/15, Icazuchi 2.5/15). The lesion was then prepared with scoring balloon (Angiosculpt 3.0/15 m) and Non-compliant balloon 3.5/15 mm at 30ATM. After achieving an acceptable angiograpic result, sirolimus was eluted within stents in the mid RCA with 2 drug coated balloon (Magic Touch 3.5/30 mm and 4.0/15 mm) at 10 ATM for 60 seconds. A with a new DES (Tansei Ultimaster 4.0/21 mm) was implanted at the ostium.

RCA restenotic occlusion was crossed with a polymeric wire (Fileder XT) and the support of a microcatheter (Supercross FT) and controlaterale injection. The wire was exchanged with a Sion Blue. The restenotic lesion was dilated with balloon (Tazuna 2.0/15, Icazuchi 2.5/15). IVUS evaluation: reference vessel diameter at mid RCA 3.0-3.5, at proximal RCA 4.0-4.5 mm The lesion was prepared with scoring balloon (Angiosculpt Spectranetics 3.0/15 m) and non-compliant balloon 3.5/15 mm at 30ATM.After achieving an acceptable angiographic result, sirolimus was eluted within the RCA segment covered with the previous implanted stent with 2 drug coated balloon (Magic Touch 3.5/30 mm and 4.0/15 mm) at 10 ATM for 60 seconds. The ostial protruding stent previously implanted partially dislodged was covered with a new DES (Tansei Ultimaster 4.0/21 mm) with postdilated with flaring with non-compliant 4.0/15mm balloon up to 28ATM.
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Historically, ISR represents the first clinical application of drug-coated balloons. The main advantage of DCB is that no new stent scaffold is needed within previously implanted stent.  This case represents an example of real-world experience of repeat angioplasty or chronic total occlusion within previously implanted DES. Intracoronary imaging allows for a better understanding of the ISR mechanism, and helps to guide the procedure with a hybrid approach including drug coated balloons and new stent when needed.