An effective treatment for repeated coronary in-stent restenosis using rotational atherectomy after aggressive wire penetration through the calcified nodule: a case report

Abstract

Background

Lesions with calcified nodules (CNs) have a significantly higher rate of restenosis. There is no definitive and effective medication or procedural technique to suppress the progression of CNs.

Case summary

A 71-year-old was referred to our hospital because of typical effort angina pectoris. Diagnostic coronary angiography identified significant severe stenosis in the middle segment of right coronary artery (RCA). In the primary percutaneous coronary intervention (PCI), intravascular ultrasound visualized the eccentric protruding high echoic structure with irregular surface indicating CNs. Percutaneous coronary intervention was successfully performed with rotational atherectomy (RA). However, one year after the PCI, effort angina was recurrent. The patient experienced recurrent restenosis three times, even after repeated PCI using RA and treatment with drug coating balloon. In the fourth PCI, we tried guide wire penetration through the CNs before RA to reduce the more amount of CNs tissue; finally, good patency was achieved. At last, follow-up angiography after final PCI showed no in-stent restenosis.

Discussion

We report a case of a patient who required repeated revascularization to a severe stenotic lesion with CNs in the middle segment of the RCA. Rotational atherectomy after wire penetration into the CNs was effective to avoid a malignant cycle of restenosis.

Learning points.

• Lesions with calcified nodules (CNs) have a significantly higher rate of restenosis, even after percutaneous coronary intervention using rotational atherectomy (RA) or treatment with drug coating balloon.

• The strategy of using RA after wire penetration through the CN has the potential to stop the malignant cycle of coronary in-stent restenosis.

Introduction

Lesions with calcified nodules (CNs) have a significantly higher rate of clinically driven target lesion revascularization (CD-TLR), including stent thrombosis, than those without CNs, especially within 1 year.¹ There is no definitive and effective medication or procedural technique to suppress the progression of CNs.

Here, we report a case of a patient who required repeated revascularization to a severe stenotic lesion with CNs in the middle segment of the right coronary artery (RCA).

Summary figure

Case presentation

A 71-year-old man was referred to our hospital because of typical effort angina pectoris. Exercise stress test was performed, which showed stent thrombosis (ST) depression with typical angina. Even after administration of the maximum tolerated dose of medication including beta blocker, Ca-antagonist, symptoms did not improve sufficiently. However, medication didn't improve symptoms sufficiently.

Diagnostic coronary angiography (CAG) identified significant severe stenosis in the middle segment of the RCA (see Supplementary material online, Video S1), so percutaneous coronary intervention (PCI) was performed. Preprocedural intravascular ultrasound (IVUS) was used to visualize the eccentric protruding high echoic structure with an irregular surface indicative of CNs. Rotational atherectomy (RA) with a 1.5-mm burr was performed, then numerous CNs were still observed by IVUS. Therefore, an additional RA was performed using a 2.0-mm burr, followed by balloon dilatation with 3.0 mm. We obtained an acceptable acute lumen gain, implanted 4.0-mm bioabsorbable polymer coated platina–chromium everolimus-eluting stent (Boston Science Corporation, Marlborough, MA, USA) and performed postdilatation with a 4.0-mm noncompliant balloon, achieving sufficient stent expansion (Figure 1 and Supplementary material online, Video S2).

Figure 1.

Primary percutaneous coronary intervention for the calcified nodule. (A) Coronary angiography before percutaneous coronary intervention). Severe stenosis caused by calcified nodules in the middle segment of the right coronary artery (arrow). (B, C) Initial percutaneous coronary intervention. Balloon dilatation after rotational atherectomy, and final coronary angiography after the implantation of drug-eluting stent. The white dotted line indicates the segment of the stent.

Dual antiplatelet therapy with aspirin (100 mg) and prasugrel (3.75 mg) was continued after PCI. However, one year after index PCI, effort angina recurred. Coronary angiography revealed severe eccentric in-stent restenosis (ISR) due to CNs (see Supplementary material online, Video S3), and secondary PCI was performed. Preprocedural optical frequency domain imaging tomography (OFDI) showed in-stent eccentric CNs (see Supplementary material online, Video S4). Predilatation was performed with a 4.0-mm scoring balloon, finalized by a 4.0-mm drug coating balloon (DCB) (SeQuent Please NEO, B. Braun Berling, Germany) (see Supplementary material online, Videos S5 and S6).

Six months after the second PCI, unfortunately, CAG revealed ISR, as well as deteriorating stenosis compared to the lesion at the time of the previous session (see Supplementary material online, Video S7). Consequently, a third PCI was performed.

Optical frequency domain imaging tomography was not passed, so we decided to perform RA with a 1.5-mm burr. After RA, OFDI revealed in-stent CNs as well as second PCI (see Supplementary material online, Video S8), and then size-up 2.0-mm burr to reduce the calcium volume. The lesion was dilated with a 4.0-mm scoring balloon and finalized with a 4.0-mm DCB (Figure 2 and Supplementary material online, Videos S9 and S10).

Figure 2.

Second in-stent restenosis 6 months after the second percutaneous coronary intervention. (A) Coronary angiography before the procedure. Restenosis within the previously implanted drug-eluting stent. (B) Angiography after rotational atherectomy with a 2.0-mm burr. (C) Final angiography. (D) Optical frequency domain imaging catheter couldn’t pass due to severe stenosis. Optical frequency domain imaging after rotational atherectomy with a 2.0-mm burr (a). Asterisks indicate in-stent eccentric calcified nodules. Final optical frequency domain imaging images (a′). Eccentric protruding calcified nodules (asterisk) were reduced and compressed.

The patient was followed up in outpatient regularly. And the patient complained of recurrent effort chest pain 6 months after the third PCI.

Because CAG revealed restenosis (see Supplementary material online, Video S11), we recommended coronary artery bypass grafting. But he rejected it. We decided to perform fourth PCI. Aiming to overcome the malignant recurrent restenosis cycle, we attempted guide wire penetration through the CNs to reduce the amount of CNs tissue to perform more aggressive debulking and to improve lesion eccentricity. After advancing the first guide wire to the stenosis, we navigated the second guide wire into the CNs with IVUS guidance. Conquest Pro 12 (ASAHI Intec, Japan) successfully penetrated through the CNs to the distal lumen and micro-catheter, as did the Corsair Pro (ASAHI Intec, Japan) (Figure 3 and 4 and Supplementary material online, Video S12). Then, RA was performed with a 1.5–2.0-mm burr. Intravascular ultrasound after RA showed effective ablation of CNs (see Supplementary material online, Videos S13 and S14). Finally, we dilated with a 4.0-mm scoring balloon and finalized it with a 4.0-mm DCB. The lumen was rounder and straighter compared to that of the previous session by final IVUS and angiography (Figure 3 and Supplementary material online, Video S15).

Figure 3.

Third in-stent restenosis 6 months after the third percutaneous coronary intervention. (A) Coronary angiography before the procedure. Arrow indicates the position of stent edge. (B) Angiography after rotational atherectomy using a 2.0 burr. (C) Final angiography. (D) Intravascular ultrasound images after rotational atherectomy with a 2.0-mm burr following aggressive wire penetration through calcified nodules on the whole circumference (a) and final intravascular ultrasound images (a′).

Figure 4.

Explanation of step-by-step aggressive wire recanalization in calcified atheroma and dilatation at third in-stent restenosis. Step 1: After the first guidewire has passed through the lesion, the second guidewire penetrated into the calcified nodule while confirming the puncture point with intravascular ultrasound. (A: cine image, B: schematic figure of image A and cross-sectional image of intravascular ultrasound). Step 2: Wire manipulation with check wire trajectory in two projection angles of stent-enhanced image ∼90° apart (C).

Follow-up angiography was scheduled 6 months after the final PCI and showed no ISR. The lumen of the lesion was almost the same as that of the final angiography at the time of the fourth PCI (Figure 5 and Supplementary material online, Video S16).

Figure 5.

Follow-up coronary angiography. Half-year follow-up coronary angiography after the fourth percutaneous coronary intervention. No in-stent restenosis and lumen of the lesion were retained (arrow).

Discussion

Refractory ISR after PCI to CNs is presumably derived by repeated protrusion of CNs rather than neointimal hyperplasia. Mechanism of restenosis is significantly different from that of non-CNs and highlights CNs as high-risk lesions that require repeat revascularization.^2–4 Intravascular lithotripsy have been reported have the effective to obtain lumen gain for CNs.⁵ Although the use of such devices should be considered, we speculated that it would be difficult to achieve an effect beyond the effect of volume reduction in RA under the circumstances of this case of restenosis, so we tried this technique.^6,7

In endovascular therapy for eccentric calcified lesions, aggressive wire recanalization in calcified atheroma and dilatation (ARCADIA) was introduced as a safe and effective method.⁸ In the present case who required repeated PCI using RA and treatment with DCB, good patency was achieved after the fourth PCI using ARCADIA following RA and dilatation with DCB. Previous registry data investigating stent thrombosis of second-generation drug-eluting stents reported that ST in the in-stent CNs group exhibited significantly more asymmetric and eccentric stent expansion than in the non-in-stent CNs group. Additionally, in-stent CNs were found to be independently associated with TLR after index ST events. This indicates that eccentric and asymmetric progress in-stent CNs development through accelerated fibrin and thrombus formation in the lesion is due to disturbance in the distal part of the eccentric site.⁹

Therefore, we assume that the reason why we could stop the malignant cycle of restenosis in this case is as follows:

Penetrating the wire through the CNs changed the ablation course of the rota burr from the major curvature side of the vessel to the minor curvature side of the lumen.

1. It enabled us to perform more aggressive volume reduction of CNs, leading to a larger acute gain.

2. It could improve the lesion eccentricity of the target lesion and protect against the progression of CNs.

Aggressive wire recanalization in calcified atheroma and dilatation is more difficult to perform in the coronary artery compared to the peripheral artery because of smaller vessel size. The wire penetration through the CNs is an uncertain technique given that a guide wire with a higher penetration force is required. Moreover, the success of the procedure depends on the lesion morphology. Additionally, operators should pay attention to vessel perforation by the stiff wire. So, we must emphasize that this technique is not the first-choice technique and should be performed only by skillful operator because of the risk of wire going through behind stent strut and the risk of wire perforation.

The key point of this technique is to accurately and safely penetrate the wire in the proper position, i.e. the centre of the CNs. I have successfully penetrated the wire under the following two tips (Figure 4).

1. Setting the penetration wire position with simultaneous IVUS observation.

2. The wire penetrates the centre of the CNs with the stent as a landmark at two projection angles at least 90° apart so that the wire maintains its position not too close to the stent strut.

The outcomes of drug-eluting balloon (DEB) or drug-eluting stent (DES) for in-stent CNs have not been well reported.

However, it is generally understood that the target lesion revascularization rates are relatively high even after treatment by DES and DCB.

Currently, DES implantation in the treatment of in-stent CNs is associated with the possibility of limiting further treatment strategies, such as the use of debulking devices for future restenosis. Therefore, we believe that strategy without additional stent is appropriate as much as possible.

Conclusion

We successfully treated repeated ISR lesions with aggressive wiring through CNs followed by RA and dilatation with DCB. Despite several limitations, this case suggests that the present technique has the potential to stop the malignant cycle of coronary ISR caused by CNs.

Lead author biography

Dr Yasuo Tsuru, MD, is a clinical fellow of cardiology in Kokura Memorial Hospital.

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports online.

Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance.

Funding: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.