Abstract
A 33-year-old male developed pulmonary vein (PV) stenosis 3 months after PV isolation for atrial fibrillation. Stents were implanted in the left superior and inferior PVs, but 2 years later, in-stent restenosis occurred. Intravascular ultrasound and nonobstructive general angioscopy (NOGA) revealed severe ostial stenosis and neointimal hyperplasia. Drug-coated balloon angioplasty was performed, and NOGA confirmed paclitaxel deposition. This case highlights the utility of NOGA for directly visualizing neointimal changes and drug delivery, which are not assessable by intravascular ultrasound alone. This is the first report to demonstrate in-stent restenosis and post–drug-coated balloon changes in the pulmonary vein using NOGA.
Key words: angioscopy, atrial fibrillation, neointimal hyperplasia, pulmonary vein intervention, vascular imaging
Graphical Abstract
A 33-year-old male underwent pulmonary vein isolation (PVI). Three months later, he developed fever, hemoptysis, and cough. Contrast-enhanced computed tomography (CT) images before (Figure 1A) and 3 months after (Figure 1B) PVI suggested pulmonary vein stenosis (PVS) in the left superior pulmonary vein and left inferior pulmonary vein (LIPV). Left atrial angiography confirmed significant PVS in both veins (Figures 2A and 3A). Stents were placed in the left superior pulmonary vein (Express LD; 8.0 × 17 mm) and LIPV (Express SD; 7.0 × 19 mm) (Figures 2B and 3B).
Figure 1.
Contrast-Enhanced Computed Tomography
(A) Pre-pulmonary vein isolation; (B) pulmonary vein stenosis diagnosis; (C) poststenting; (D) in-stent restenosis. LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein.
Figure 2.
Left Atrial Angiography Near LSPV
(A) Ostial occlusion; (B) stented left superior pulmonary vein (LSPV); (C) in-stent restenosis; (D) post–drug-coated balloon (DCB).
Figure 3.
Left Atrial Angiography Near LIPV
(A) Stenosed left inferior pulmonary vein (LIPV); (B) stented LIPV; (C) in-stent restenosis; (D) post–drug-coated balloon (DCB).
Two years later, he presented with hemoptysis and cough. CT 1-month poststenting (Figure 1C) showed patency, but 2-year CT revealed in-stent restenosis in the LIPV (Figure 1D). Left atrial angiography confirmed restenosis in both stents (Figures 2C and 3C). Intravascular ultrasound (IVUS) demonstrated severe pulmonary vein ostial stenosis with attenuation (Figure 4A). Nonobstructive general angioscopy (NOGA) showed a white intima without thrombus or yellow lesions (Figure 4B), with complete neointimal coverage over stents (Figure 4B), indicating neointimal hyperplasia. Both pulmonary veins underwent drug-coated balloon (DCB) dilation (Figures 2D and 3D). Postdilation IVUS showed intimal compression (Figure 4C), while NOGA revealed paclitaxel deposition (Figure 4D).
Figure 4.
IVUS and NOGA in LIPV
(A) Intravascular ultrasound (IVUS) pre–plain old balloon angioplasty (POBA); (B) nonobstructive general angioscopy (NOGA) pre-POBA; (C) IVUS post-DCB; (D) NOGA post-DCB. White arrowheads indicate the previous stent; yellow arrowheads indicate paclitaxel particles. Abbreviations as in Figure 3.
Severe PVS after PVI occurs in 0.7% of cases.1 Stent placement reduces restenosis compared with plain old balloon angioplasty.2 However, the mechanism of restenosis after stenting remains unclear. IVUS and NOGA identified neointimal hyperplasia as the primary cause. DCBs deliver paclitaxel, which induces fibroblast and smooth muscle cell apoptosis, making them a promising option for PVS treatment.3 NOGA provides direct visualization of the vascular surface, including neointimal coverage and drug deposition, which cannot be assessed by IVUS alone. However, its clinical application is limited due to the need for specialized equipment and expertise, as well as restricted insurance coverage and limited availability outside Japan.
This is the first report to visualize in-stent restenosis and post-DCB findings using NOGA.
Funding Support and Author Disclosures
Dr Okumura has received research funding from Medtronic Japan, MicroPort CRM Japan, and Bayer Healthcare; has accepted remuneration from AstraZeneca and Johnson & Johnson; and belongs to the endowed departments of Boston Scientific Japan, Abbott Medical Japan, Japan Lifeline, Medtronic Japan, and BIOTRONIK Japan. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Take-Home Message
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NOGA offers direct visualization of in-stent restenosis and drug delivery, which may help clarify mechanisms and guide future treatment.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
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