Very Long In-Stent Restenosis Treated by Cutting Balloon Angioplasty and Beta-Radiation Therapy using 188Re Filled Balloon

- Operator : Alan C. Yeung

Very Long In-Stent Restenosis Treated by Cutting Balloon Angioplasty and Beta-Radiation Therapy using 188Re Filled Balloon

- Operator : Alan C. Yeung, MD

Case Presentation
The patient was a 45 year-old man. In December 2002, he had a myocardial infarction and was treated with a 3.5 x 30 mm S7 stent and a 3.0 x 30 mm S7 stent with minimal overlap in mid to distal RCA. His coronary risk factor was hypertension. Baseline ECG revealed normal. Treadmill test showed positive results at stage 3. Echocardiography showed good LV function.
Baseline Coronary Angiography
1. Normal left coronary artery

2. Rright coronary angiogram showed diffuse moderate to severe in-stent restenosis from mid RCA to distal RCA, not involving branching point (Figure 1).
Intravascular ultrasound
IVUS image showed tight stenosis with neointima from middle RCA to distal RCA (Figure 2). Stent lumen CSA was 6.51mm2
Procedure
A 7F Judkins guiding catheter was engaged at the ostium of RCA. A Floppy guidewire was placed from RCA to the posterior descending artery. The RCA lesion was dilated 4 times using a 3.0 x 10mm cutting balloon (Figure 3, Figure 4). After cutting balloon angioplasty, coronary angiogram showed successful treatment of the in-stent restenotic (ISR) lesion (Figure 5). After then, the radioactive source (a 3.0 x 40mm balloon filled with liquid 188-Re) was inserted into the RCA ISR lesion and inflated to 6 atm (Figure 6). However, the ISR lesion was not radiated with a single long balloon dilatation. Therefore, manual stepping of radiation therapy was done with minimal overlapping (Figure 7). The dwell time lasted 267 seconds that delivered 20Gy to a depth of 1.0mm from the balloon-neointima interface. The post-intervention angiogram showed severe narrowing probably due to plaque shift at posterolateral (PL) branch (Figure 8). Thus balloon angioplasty with a 2.5 x 20 mm balloon at 8 atm was performed (Figure 9). Following angiogram revealed dissection confined to PL branch (Figure 10). And then the dissection was treated with a 2.5 x 18 mm BX stent at 8 atm. Final angiogram showed a good result without significant residual narrowing or dissection (Figure 11).

Comments

  • Jae Yoon Go 2003-05-31 goog result
  • Gamal Abu-Omar 2003-06-02 Good result, but it would be better, in my mind, if you treat this with a DES; more simple technique, better immediate and long term result, nearly the same cost after you had put a BMS to the PL branch which caused a plaque shift to the origin of the intermediate branch
  • Seung-Jung Park 2003-06-19 I agree with your suggestion. The long-term efficacy DES for the ISR, especially for the diffuse ISR, would be still premature. For particular this case, the lesion length was very long more than 60mm and so we did radiation. The brachytherapy is the only proven effective treatment modalaity for this kind of lesion so far.

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