J INVASIVE CARDIOL 2019;31(11):E333-E334.
Key words: angiography, cardiac imaging, in-stent restenosis, optical coherence tomography
A 59-year-old, non-diabetic, non-smoker male presented with rest angina in August 2006. Coronary angiography revealed the separate ostial origin of an anomalous left main (LM) arising from the right coronary sinus with a retroaortic course (Figure 1A). The proximal and distal left anterior descending (LAD) artery each had a type B lesion (Figures 1A and 1B), and were successfully stented using 3 x 23 mm and 2.5 x 23 mm sirolimus-eluting Cypher stents (Cordis), respectively (Figures 1C and 1D). A computed tomography scan confirmed separate ostial origin and retroaortic course of the LM (Figure 2). He remained asymptomatic during regular outpatient department follow-up visits for the next 12 years. In December 2018, he presented with exertional angina of 2-month duration. Coronary angiography revealed proximal in-segment in-stent restenosis (ISR) of the ostial and distal LAD stents (Figures 3A and 3B). Optical coherence tomography revealed significant LM shaft stenosis (Figure 3C´) along with ISR of both stents (Figures 3A´ and 3B´). Following cutting-balloon predilation of both ISR sites, a 3 x 38 mm Synergy everolimus-eluting stent (Boston Scientific) was deployed in the mid LAD (Figure 4A) and a 4 x 20 mm Synergy stent was deployed from LM-LAD (Figure 4B). The remaining LM shaft was covered with 2 overlapping 4 x 16 mm and 4 x 38 mm Synergy stents (Figure 4C). Proximal optimization of the LM was performed using a 5 x 12 mm non-compliant balloon. Ostial left circumflex was dilated with a 2.5 x 15 mm balloon only, without implantation of a stent (Figures 4B and 4C). Optical coherence tomography revealed well-apposed stents across the LM-LAD without any significant residual stenosis or edge dissection (Figures 4A´-4C´). He was asymptomatic at 2-month follow-up exam at the outpatient department.
This is a rare case of very late ISR of Cypher stents 12 years after PCI in a case of a single anomalous coronary.
From the Department of Cardiology, Post Graduate Institute of Medical Education & Research, Chandigarh, India.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted February 11, 2019.
Address for correspondence: Prof (Dr) Rajesh Vijayvergiya, MD, DM, FSCAI, FISES, FACC, Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Sector 12, Chandigarh – 160 012, India. Email email@example.com