Clinical Images

IVUS-Guided High-Pressure Non-Compliant Balloon Dilation to Treat In-DES Restenosis

George Kassimis, MD, MSc, PhD;  Niket Patel, MBBS, BSc(Hons), MRCP;  Adrian P. Banning, MBBS, MD

George Kassimis, MD, MSc, PhD;  Niket Patel, MBBS, BSc(Hons), MRCP;  Adrian P. Banning, MBBS, MD

A 56-year-old, non-diabetic male with previous bare-metal stent (BMS) to the left anterior descending (LAD)/first diagonal (D1) bifurcation presented with exertional angina. Angiography showed significant in-stent restenosis (ISR) of the proximal LAD (Figures 1A and 1B, red arrow). The D1 was occluded, as previously documented. The right coronary artery and circumflex were unobstructed. Angioplasty to the ISR was performed with a 3.0 x 32 mm drug-eluting stent (DES). Postdilatation with up to a 4.0 mm non-compliant (NC) balloon was required due to a focal area of stent waisting. Partial success was achieved (Figure 1C, red asterisk). He re-presented with recurrent angina and angiography demonstrated significant focal ISR with strut crowding at the site of previous stent underexpansion (Figure 1D, red arrow). Intravascular ultrasound (IVUS) demonstrated multiple layers of stents with a focal tight area of stent underexpansion (Figure 1E). IVUS-guided angioplasty with high-pressure balloons was planned. A 3.0 x 15 mm high-pressure OPN NC balloon (Vascular Perspectives) inflated to 40 atm failed (Figures 1F), and subsequent IVUS showed a minimal lumen area (MLA) of 3.9 mm2 (Figure 1G). Further inflations with a 3.5 x 10 mm OPN NC up to a pressure of 43 atm yielded angiographic success (Figures 1H and 1J). The balloon-injured area was then treated with a 3.5 x 15 mm paclitaxel-coated balloon deployed at a pressure of 18 atm for 120 s (Figure 1I). IVUS confirmed an MLA of 6.2 mm2 (Figure 1K). The patient remains angina and event free more than 12 months post angioplasty. The OPN NC balloon appears to offer a new means of dilating underexpanded stents when other NC balloons have failed. 

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From the Oxford Heart Centre, John Radcliffe Hospital, Oxford, United Kingdom.
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.
Manuscript submitted November 11, 2013, provisional acceptance given November 14, 2013, final version accepted November 22, 2013.
Address for correspondence: George Kassimis, MD, MSc, PhD, Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, United Kingdom. Email: gksup@yahoo.gr

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