A 63-year old male was presented with effort chest pain for 1 month. Risk factor was hypertension. Echocardiography showed no wall motion abnormality with normal systolic function.

Right coronary angiography revealed a diffuse, severe stenosis at the middle to distal segment of right coronary artery (Figure 1, Figure 2). Left coronary angiography was normal

1. Index procedure

A 7F Judkins guiding catheter was engaged at the ostium of the RCA. A Floppy guidewire was placed into the RCA. The lesion was predilated with a 2.5 x 20mm conventional balloon at 10atm. After predilatation, three cypher stents (3.0 x 18mm, 3.0 x 18mm, 2.75 x 23mm) were implanted with overlapping (Figure 3, Figure 4, Figure 5). Final angiography showed well deployed stent without residual stenosis or dissection and the presence of TIMI 3 flow (Figure 6).

2. Six-month follow-up angiogram

A 6-months follow-up angiogram showed patent all stents without instent restenosis (ISR) (Figure 7, Figure 8)

3. Two-year follow-up angiogram and target lesion revascularization

This patient was re-admitted to our hospital with recurrent chest pain. A 2-year follow-up angiogram showed a focal ISR at proximal edge of the middle RCA stent and at distal RCA stents (Figure 9, Figure 10). A distal ISR site showed a disrupted continuation of the overlapped stents, suggesting the stent fracture (Figure 11). A distal ISR site was treated with balloon angioplasty and a proximal ISR site was implanted with additional cypher stent (3.5 x 33mm) (Figure 12, Figure 13). Final angiogram showed good results without residual stenosis (Figure 14, Figure 15).

4. Follow-up angiogram after target lesion revascularization

Follow-up angiogram 6-months later after re-intervention showed new focal ISR at middle portion of the middle RCA stent and the distal RCA stent, which were different sites from previously treated ISR sites (Figure 16, Figure 17, Figure 18). Interestingly, proximal ISR site revealed a discontinuation of stent, suggesting recurrent stent fracture of the target vessel (Figure 19, Figure 20).

Because the functional stress test, such as treadmill test and thallium SPECT, did not show objective evidence of ischemia, this patients was treated with medication alone.