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Relevant clinical history and physical exam
A 90’s year-old male admitted with chest pain. His coronary risk factors were hyperlipidemia, hypertension and diabetes mellitus. He is chronic kidney failure patient (BUN 15.6 mg/dl, SCR 1.10 mg/dl, eGFR 48.0 ml/min). ECG showed normal without ST changing. Echocardiography showed a normal left ventricular ejection fraction of 60%. This case is repeated in-stent restenosis of the bifurcation of a Left anterior descending artery (LAD) and left circumflex artery (LCX).
Relevant test results prior to catheterization
He underwent stenting Cypher stent 3.0 × 28 mm (Cordis) at proximal LAD and stenting TAXUS stent 3.0 × 16 mm (Boston Scientific) at proximal left main trunk (LMT) to LAD with overlapping the stent nine years ago. Because of the progressing stenosis at LCX ostium he received stent LMT-LCX with mini crush (Cypher 3.0 × 18 mm). After that in-stent restenosis of LCX ostium occurred several times and done balloon angioplasty with kissing balloon technique each time.
Relevant catheterization findings
However, re stenosis occurred at shorter interval times. Then he underwent Excimer laser Catheter ablation for LAD and LCX and was deployed Noobori stent 4.0 × 13 mm (Terumo) at middle LMT to LCX ostium lesion. After the eight months, Coronary angiogram showed 90% stenosis of the proximal LAD.
We inserted an intra-aortic balloon pumping (IABP) into the left femoral artery for hemodynamic support during the intervention. A 7Fr EBU 3.5 catheter was engaged into the left coronary ostium.(Fig.1) The LAD was wired with a 0.014 inch Sion blue and LCX was wired with a 0.014-inch Run through Hypercoat. IVUS examination showed that there was concentric soft plaque in-stent at LMT distal to LAD ostium and LCX ostium. We dilated LAD using scoring balloon ( Lacross NSE 3.5 × 13 mm, Goodman) 14 atm. After pre-dilation IVUS examination showed that the plaque at LAD lesion decreased and plaque shift was not showed at LCX lesion. Finally, we done kissing balloon to the bifurcation lesion at LMT to LAD and LCX using drug-coated balloon (Sequent Please 3.5 × 20 mm at LAD and 3.0 × 20 mm at LCX, Nipro) (Fig.2).These balloons were inflated 10atm 30seconds. IVUS examination showed the plaque decreased and minimum lesion diameter 2.5 mm at LAD and stenosis did not remained LCX. It was successful procedure.(Fig.3)
We undertook kissing balloon dilation for the repeated in-stent restenosis at the bifurcation LMT to LAD and LCX using drug-coated balloons. One year after the procedure, following coronary angiogram showed that coronary stenosis did not progress at the lesion.He had not developed angina for two years from the final procedure. Treatment for coronary in-stent restenosis at bifurcation lesion with a drug-coated balloon is effective.