Rotational atherectomy is useful to treat the restenosis lesion of LCX after Culotte-Stenting to LMCA bifurcation lesion

- Operator : Hiroyuki Nagai

Rotational atherectomy is useful to treat the restenosis lesion of LCX after Culotte-Stenting to LMCA bifurcation lesion
- Operator: Hiroyuki Nagai, MD
Relevant clinical history and physical exam

A 57 year-old gentleman visited our hospital because of recurrent chest pain. His coronary risk factors were hypertension, dyslipidemia, and diabetes. He already underwent several PCIs for RCA, LAD, and LCX. Three years ago, he received the implantation of Cypher stent (3.5*23, 3.0*28, 2.5*8) at mdRCA and Cyper stent (3.0*28) at mLAD. And 1 year ago, Taxus stent 3.0*16 at dLAD, Taxus stent 2.5*32 at dLCX were implanted. Nine months before, Cypher 3.0*18 at dRCA was implanted again.

Relevant catheterization findings

Left coronary angiogram showed severe stenosis in LCX and LAD ostium (Figure 1, Figure 2).

Procedural step

Culotte steting for LMCA was performed. Cypher stent (3.5*33) was placed in LMCA-LAD. And Cypher stent (3.0*28) was placed in LMCA-LCX. Successful dilatation was obtained (Figure 3, Figure 4). However, 6 month later, follow up angiogram showed restenosis at LCX ostium, which was jailed by the Cypher stent implanted from LMCA to LAD (Figure 5, Figure 6). We slowly and gently advanced 2-mm and 2.25-mm burr without reducing the rotational speed by more than 5,000 rpm to ablate the stent struts which was obstacle for the LCX ostium ( Movie 1, Movie 2, Figure 7). After ablating stent struts, We dilated LCX ostium. Balloon size was 3.75mm. Maximum EEM diameter was 4.3mm in LCX ostium by IVUS. And we dilated LMCA, LAD, LCX with kissing balloon technique (Figure 8). The dilatation after culotte stenting showed napkin ring like a figure, because the maximum dilation diameter of SES struts is 2.75 mm. After kissing balloon technique, successful dilatation was obtained in LMCA, proximal LAD and LCX ( Movie 3, Movie 4). Three months later, there was no restenosis ( Movie 5, Movie 6).

Comments

  • Marcelo Ribeiro 2009-11-22 Dear coleague, I certainly had for several years seen anecdotal reports of rota-ablation of previous implanted stents, and sincerely I would have debated over its application in this case; this gentleman has already seven DES stents in his coronaries, and still ostial disease in secondary branches plus the restenotic proccess. Besides that, what is the size of the metal particles that you have disrupted, what was its destiny? What happens to the vessel wall in terms of heat exposure, for example? My point is, this is not scientific medicine, it has worked for 3 months in this case, which does not prove that it is ethically right.I would have sent this patient to surgery, after discussing the best way to deal with the antiplatelet therapy. Best regards,

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