TITLE: Complex Intervention of an In-Stent Restenosis of Ostial Right Coronary Artery Stent Protruding into Aortic Sinus of Valsalva: A Case Report and Brief Review of the Literature
From the *Department of Internal Medicine, Detroit Medical Center, Detroit, Michigan, the §Division of Cardiology, Wayne State University/Detroit Medical Center, Detroit, Michigan, and the £Department of Internal Medicine, Division of Cardiology, Wayne State University/Detroit Medical Center, Detroit, Michigan. The authors report no conflicts of interest regarding the content herein. Manuscript submitted April 13, 2009, provisional acceptance given April 27, 2009, and final version accepted May 27, 2009. Address for correspondence: Luis Afonso, MD, FACC, Associate Professor of Medicine, Division of Cardiology, Wayne State University, Harper University Hospital, 8 Brush St., 3990 John R., Detroit, MI 48201. E-mail: email@example.com or firstname.lastname@example.org
ABSTRACT: Aorto-ostial lesions are technically challenging for interventionists and have high restenosis rates. Proper placement of the stent is critical for prevention of future complications in these lesions. We describe a case in which the ostial right coronary artery stent with severe in-stent restenosis was protruding too far into the aorta, causing significant difficulty in engaging the guidewire in the true lumen. The stenosis was finally tackled through the side of the stent and the restenosis was successfully restented.
J INVASIVE CARDIOL 2009;21:E226–E228
Aorto-ostial lesions are technically challenging for interventionists and have a high rate of restenosis, even in the present era of drug-eluting stents.1–3 Current stenting practice advocates a small degree of protrusion of the stent into aorta to effectively tackle the ostial lesion.4 However, improper placement may result in increased frequency of restenosis and complicate future access and intervention on the stenosed stent, particularly in terms of engaging the stent with the catheter.5 We describe one such case of a patient who presented with a stent protruding too far into the aorta and was successfully treated using a complex interventional technique. Case Presentation. A 61 year-old African-American female presented to the emergency room with a history of left-sided chest pain with radiation to the left arm of 1-hour duration. The patient reported experiencing similar symptoms over the previous few days which worsened with exertion, but were of lesser intensity. An evaluation revealed no electrocardiographic or biochemical evidence of myocardial infarction. However, the patient underwent coronary angiography due to her history of coronary artery disease and previous history of percutaneous coronary intervention to treat an ostial right coronary artery (RCA) lesion. Angiography revealed severe in-stent restenosis of the previously placed stent, with approximately 5 mm of the stent protruding into the aorta (Figures 1–3). Repeated attempts to engage the protruding end of the stent using several different guiding catheters were unsuccessful. Ultimately, the stent was engaged from the side using a JR4 guide catheter and the ostial RCA in-stent restenosis was wired using an Asahi 300 soft wire (Abbott Laboratories, Abbott Park, Illinois) followed by serial dilatations initially using 2.0 x 20 mm and then 3.0 x 20 mm Rapid-Exchange balloons (Medtronic, Inc., Minneapolis, Minnesota). Due to instability of the guide catheter, it was decided that a Wiggle wire (Guidant Corp., Indianapolis, Indiana) be used to provide more support. A 2.0 x 20 mm Maverick over-the-wire balloon (Boston Scientific Corp., Natick, Massachusetts) was used over the Asahi soft wire which was exchanged for a Wiggle wire, followed by angioplasty using a 3.0 x 15 mm noncompliant balloon at high pressure. Next, a 3.5 x 12 mm Cutting Balloon (Boston Scientific) was used to perform angioplasty. After multiple episodes of catheter disengagement and subsequent reengagement of the stent from the side during the procedure, an Endeavor 3.5 x 13 mm drug-eluting stent (Medtronic) was successfully delivered in the ostial RCA at 14 atmospheres (atm) following which postdilatation and flaring was done using a 3.5 x 13 mm PowerSail noncompliant balloon (Abbott Vascular). Final angiographic images showed excellent results (Figure 4) and the patient tolerated the procedure well. Discussion. Aorto-ostial stenosis poses a unique challenge for interventionists. A technically difficult intervention even in native lesions, aorto-ostial lesions are also more prone to complications including high rates of in-stent restenosis.1–3 These issues render reintervention on such lesions a technical nightmare. Current practice proposes stenting of aorto-ostial lesions with a short overhang, usually 1–2 mm, into the aorta so as to cover the entire ostial lesion, which is of critical importance. Excessive deviation from the required protrusion may result in complications, especially since excess overhang makes subsequent intervention difficult.4,5 As described in our case, the ostial RCA stent was protruding nearly 5 mm into the aorta (Figures 1–3), and the possibility that the stent end was deformed made it impossible to engage several different guide catheters in the true lumen, despite repeated attempts. In a previous case report a double-wire technique has been described to help support and guide the engagement of the true lumen of the stent, which could not be done in our case due to deformation of the stent.6 Although complications have occurred when passing catheters through the side of the stents, with careful manipulation, successful intervention of these complex lesions can be done by using the stent side or passing through the struts access as a last resort.4,5,7 Recently, the Ostial Pro Catheter (Ostial Solutions, LLC, Kalamazoo, Michigan), a new FDA-cleared device, has been used to help with appropriate placement of the stent in aorto-ostial lesions. However, further studies need be conducted to determine the effectiveness of such devices.8 In conclusion, our case report emphasizes the practical challenges of intervening on aorto-ostial lesions, particularly with respect to accurate initial placement of stents to prevent excessive overhang. This is imperative, as repeat interventions on previously stented aorto-ostial lesions are technically difficult and are associated with an increased risk of procedural complications.