Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
AGB is a 64 year old man with underlying end stage renal failure on regular haemodialysis, diabetes mellitus (currently well controlled and not on insulin), hypertension and history of left below knee amputation secondary to diabetic foot disease. He complained of chest pain and hypotension during haemodialysis.
Relevant test results prior to catheterization
He had a coronary angiography performed on the 30th June 2014. This revealed a significant lesion at ostial to a proximal left anterior descending artery and mid left anterior descending artery. Moderate lesion at a proximal obtuse marginal artery. Right coronary artery is recessive and diffusely diseased. He was referred to the cardiothoracic surgeon for coronary artery bypass grafting. However, the surgeons declined to operate citing high procedural risk.
Relevant catheterization findings
He presented to the cardiology team for the same symptoms of chest pain and hypotension during dialysis. A repeat coronary angiogram was performed on the 10th February 2015 and percutaneous coronary intervention performed from mid to left main stem with a Xience V (Abbott Vascular) 2.75 x 28 at mid left anterior descending and Xience V (Abbott Vascular) 3.5 x 18 at left anterior descending to a left main stem. The procedure ended with a kissing balloon using non-compliant Sprinter (Medtronic, US) 3.0 x 12 in left main and 2.75 x 9 in circumflex artery. TIMI III flow was achieved. He discharged well.
However, he developed chest pain during haemodialysis again 4 months later. Angiogram revealed severe stenosis in proximal circumflex and severe in stent restenosis in proximal left anterior descending artery stent. Stented with Endeavor Resolute (Medtronic, US) 3.0 x 15 at proximal circumflex and Combo (Orbus Neich) 4.0 x 15 in left main to left anterior descending artery. Final kissing with non-complaint balloons 3.5 x 12 in left main to left anterior descending and 2.75 x 12 left main to circumflex artery.
10 months later, he developed unstable angina. Angiogram revealed near total closure of the obtuse marginal artery and severe instent restenosis of both left anterior descending and circumflex artery. The obtuse marginal was stented with Xience V (Abbott Vascular, US) 2.5 x 15 and in stente restenosis dilated with Non Complaint balloons Trek (Abbott Vascular, US) 3.0 x 15 in Circumflex and 4.5 x 15 in left main to left anterior descending. The intravascular ultrasound performed in left anterior descending and circumflex showed well-apposed stent struts.
3 months later, he developed non-ST elevation myocardial infarction and hypotension. Angiogram revealed severe in stent restenosis at left anterior descending artery and occluded obtuse marginal stent. Left main to left anterior descending stented with Endeavor Resolute (Medtronic, US) 4.0 x 18. Final kissing with non-compliant balloons 3.5 x 15 at left anterior descending and 3.0 x 15 at the circumflex artery.
This is a very challenging case of recurrent in-stent restenosis with multiple interventions at the left main.This is despite the stents being well apposed on intra-vascular ultrasound. Surgery would be the best option for the patient but his surgical risk is high. Other options include a use of drug-eluting balloons. He should also be considered for surveillance angiography to evaluate disease progression.