Calcified In-Stent Restenosis

HomeCirculation: Cardiovascular InterventionsVol. 5, No. 1Calcified In-Stent Restenosis Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBCalcified In-Stent RestenosisA Rare Cause of Dilation Failure Requiring Rotational Atherectomy Fernando Alfonso, MD, Jorge Sandoval, MD and Christian Nolte, MD Fernando AlfonsoFernando Alfonso From Interventional Cardiology, the Cardiovascular Institute, San Carlos University Hospital, Madrid, Spain. , Jorge SandovalJorge Sandoval From Interventional Cardiology, the Cardiovascular Institute, San Carlos University Hospital, Madrid, Spain. and Christian NolteChristian Nolte From Interventional Cardiology, the Cardiovascular Institute, San Carlos University Hospital, Madrid, Spain. Originally published1 Feb 2012https://doi.org/10.1161/CIRCINTERVENTIONS.111.966606Circulation: Cardiovascular Interventions. 2012;5:e1–e2IntroductionThe acute results of repeated interventions for patients with in-stent restenosis (ISR) are largely satisfactory, although some patients may still have recurrences.1,2 In this anatomic scenario, lack of initial angiographic success is exceedingly rare.1,2 We report a patient with "undilatable" ISR that eventually required rotational atherectomy to achieve procedural success. Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) unraveled the presence of severely calcified intrastent tissue, leading to "resistant" ISR.A 77-year-old man on hemodialysis was investigated for unstable angina. Coronary angiography revealed ISR of a bare metal stent that had been implanted in the right coronary artery 10 years before (Figure 1A). A saphenous vein graft to the left anterior descending coronary artery and a drug-eluting stent implanted at the left main toward the proximal circumflex coronary artery showed good results. Initial coronary intervention on the right coronary artery was unsuccessful because of resistant ISR. After failure of conventional balloons, 2 different noncompliant balloons eventually ruptured (20 bar) at the lesion site.Download figureDownload PowerPointFigure 1. A, Angiography (lateral projection) showing diffuse in-stent restenosis (ISR). B through D, Optical coherence tomography images revealing calcified intrastent tissue (plus sign) with variable morphology and degree of lumen obstruction (asterisk denotes wire artifact). E, Intravascular ultrasound imaging disclosing calcified ISR shadowing the underlying stent struts.At a repeated procedure performed 1 week later, OCT imaging revealed severe and diffuse calcification of the intrastent tissue (Figure 1B, 1C, and 1D) with a minimal lumen area of 1.5 mm2. Some neointimal ruptures were recognized (attributed to the previous treatment), but additional images of neoatherogenesis—as thin-cap fibroatheroma—were not present. IVUS (Figure 1E) also showed severe intrastent calcification with a "napkin-ring" image shadowing most of the stent struts. Rotational atherectomy (bur size diameter, 1.75 mm) followed by sequential repeated (the first balloon ruptured) high-pressure (up to 28 bar) noncompliant balloon inflation allowed successful lesion dilation. Subsequently, 2 overlapping everolimus-eluting stents were implanted with excellent angiographic results (Figure 2A). Optimal stent expansion was confirmed by OCT and IVUS (Figure 2B and 2C).Download figureDownload PowerPointFigure 2. Final procedural results with an optimal lumen and adequate stent expansion. A, Angiography; B, optical coherence tomography (plus sign indicates calcium within the "sandwich" stent; asterisk denotes wire artifact); and C, intravascular ultrasound.Procedural failure in patients with ISR is very rare. In some cases, however, balloon slippage phenomena may complicate these procedures.1 In other patients, severe underexpansion of the underlying stent may be very difficult to tackle, and residual underexpansion may trigger recurrent ISR.2 This problem usually results from suboptimal initial stent deployment on heavily calcified lesions.2 Finally, neoatherosclerosis—rather than classic neointimal hyperplasia—has been encountered in some patients with ISR, but the implications of this pathological finding remain unsettled.3 In this scenario, the terms "de novo " or "late atherosclerosis " might be preferred over late ISR. To the best of our knowledge, "resistant" ISR resulting from heavily calcified tissue within the stent has not been previously reported. This phenomenon was detected a decade after initial stent implantation in a patient with severe renal failure. Whether treatment of very "old" ISR should be different from that of ISR presenting within the typical time frame remains unknown. Although the implications of coronary calcification in patients on hemodialysis are well established, the presence and implications of calcified ISR in this population have not been studied.4 Rotational atherectomy was selected as the strategy of choice in our patients, although other techniques, such as cutting balloon angioplasty, may also be of value in heavily calcified lesions. The combined use of IVUS and OCT provided unique insights disclosing the underlying etiology accounting for dilation failure and proved to be instrumental to guide the repeated intervention.DisclosuresNone.FootnotesCorrespondence to Fernando Alfonso, MD, Interventional Cardiology, Cardiovascular Institute, Clínico San Carlos University Hospital, IdISSC, Madrid, Spain. E-mail [email protected]com.References1. 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