PERCUTANEOUS CORONARY INTERVENTIONS

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An approach to recurrent instent restenosis

Operators:Assoc. Prof. Mutlu Vural

Medical Sciences University Bağcılar Training and Research Hospital

Introduction

A 55-year-old woman who had a first stent restenosis in 2014 was terated with a DES implantation at the time by finding a solution (Video 1). A few months later, when the patient’s complaints started again, balloon angioplasty was applied at least two times, but after a few months the patient had complained the same again. The patient lastly came to my outpatient clinic in 2019. Despite all efforts, her angiography was almost identical to 2014 (Video 2). Since the distal end of the stent was not expansed well, it was determined that the post-stent tapering was avoided, thus avoiding high balloon pressure. At present two stents were already causing a decrease in lumen diameter in a small artery. I didn’t think of the third layer of stent. I had a different solution.

Procedure

I would repeatedly tried to dilate distal part of the stent with NC balloons of appropriate diameter (Video 3). At that time, I checked the artery distal to the distal edge of the stent at low pressures with the NC balloon and found that there were two hourglasses. I broke them without going to very high pressure. Since I didn’t think of a new stent for this area, I performed dilatation of a drug coated balloon beyon the stent (Video 4). Then, the tortuous area of the proximal region is not comfortable (Video 5). A drug-eluting stent was implanted in this region (Video 6) and postdilatations were performed. The final result was acceptable, then the procedure was terminated (Video 7 and Video 8).

Take home messages

  1. Proper lesion preparation and high pressure postdilatation are essential to prevent an ISR.
  2. High risk of restenosis when stent expansion is insufficient
  3. Drug coated balloons in ISR prevent the loss of lumen due to double, triple etc. layers of stent in small and moderate arteries.
  4. If there is already double layer of stent, drug-coated balloons should be considered.
  5. Drug coated balloons are also used in non-stent areas (more often in the periphery)

Video 1

Video 2

Video 3

Video 4

Video 5

Video 6

Video 7

Video 8

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İnstent Restenoz