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In-Stent Restenosis Lesion Treated by Rotablation
- Operator: Seung-Jung Park, MD
Case Presentation
A 80-year-old female patient was admitted for further evaluation of thallium-SPECT abnormality for the regular surveillance after PCI. She underwent PCI at the LAD and Di 11 years ago. The SPECT showed reversible large-sized perfusion defect in the mid-basal anteroseptal and apical septal wall. Her coronary angiography demonstrated discrete narrowing of previous stents at the pm LAD and Di. RCA showed diffuse stenosis but the FFR value was insignificant.
Her coronary arterial risk factor was hypertension. Her electrocardiogram showed sinus rhythm with chronic LBBB. Echocardiography revealed moderate left ventricular systolic dysfunction with akinesia of septal and mid anteroseptum.
Baseline Coronary Angiogram
  1. The right coronary angiogram showed diffuse stenosis at proximal to mid RCA. The FFR value was 0.92 ( Movie 1).
  2. The left coronary angiogram showed in-stent restenosis at proximal to mid LAD stent and diagonal stent ( Movie 2, Movie 3).
Procedure
An 8 Fr long sheath was inserted through the right femoral artery and left coronary artery was engaged with an 8 Fr XB 3.5 guiding catheter. The wire, 0.014-inch NEO’s (Sion) wire and 0.014-inch NEO’s (Sion Blue) wire were inserted into the LAD and diagonal artery (Di), respectively. After balloon dilatation at the mLAD was performed with Tazuna 1.25 x 15 mm balloon, IVUS was checked at the LAD and Di. We decided to perform rotablation for calcified in-stent restenosis lesion. A 0.014 inch Rotawire was inserted and stepwise rotablation was done with 1.75 mm burr at the LAD and Di ISR lesion ( Movie 4, Movie 5). After rotablation, high pressure balloon dilatation was performed with a Neon NC 3.0 x 20 mm balloon at the pmLAD and Di ( Movie 6, Movie 7). Then additional balloon dilatation was done at the pLAD with Sapphire NC 3.5 x 15 mm balloon. Finally, kissing balloon at the pmLAD and Di bifurcation was performed with drug eluting balloon (Pantera Lux 3.0 x 30 mm) ( Movie 8). The final angiogram showed successful results ( Movie 9, Movie 10).

Appendix
LAD IVUS image of pre-rotablation ( Movie 11)
LAD IVUS image of post high-pressure balloon (Final IVUS image) ( Movie 12)
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