Author + information
- Hiroshi Kawahara1,
- Mitsuyasu Terashima1,
- Hideaki Kaneda2,
- Maoto Habara1,
- Kenya Nasu1,
- Etsuo Tsuchikane1,
- Yoshihisa Kinoshita1,
- Tetsuo Matsubara1 and
- Takahiko Suzuki1
Patient initials or identifier number
Relevant clinical history and physical exam
A 68 year-old male with diabetes mellitus, dyslipidemia, chronic kidney disease, and a past history of smoking suffered from acute myocardial infarction. He underwent percutaneous coronary intervention (PCI) in the other hospital, and everolimus-eluting stent (EES) (XIENCE Alpine: 2.5×23 mm, Abbott, Illinois, USA) was implanted to the first diagonal branch.
Relevant test results prior to catheterization.
Relevant catheterization findings
A non-culprit lesion detected in a just proximal part of the circumflex artery (LCX) during primary PCI. Three months after the primary PCI, he referred to our hospital for the PCI to the lesion in the LCX.
To prevent a complex stenting to the left anterior descending artery (LAD)-LCX bifurcation lesion, directional coronary atherectomy (DCA) (ATHEROCUT, NIPRO, Osaka, Japan) selected for a treatment procedure. An 8Fr guiding catheter (Mach1 FCL4.0SH, Boston Scientific, Massachusetts, USA) engaged through the right femoral artery. Before DCA, we performed IVUS (OptiCross, Boston Scientific, Massachusetts, USA) and OCT (Dragonfly, St Jude Medical, Minnesota, USA) for evaluation of the lesion. They showed fibrous plaque at the myocardium side of the lesion. We performed DCA (8 times at 2 atmosphere and 5 times at 3 atmosphere), and finally implanted EES (XIENCE Alpine: 3.0 × 18 mm) at distal to the LAD-LCX bifurcation, followed by post-dilatation with 3.25 × 12 mm non-compliant balloon (Powered Lacrosse2, GOODMAN, Nagoya, Japan). Coronary artery angiography (CAG) showed a filling defect of contrast at the proximal end of implanted LCX stent. IVUS and OCT demonstrated an intimal flap at the site corresponding to a filling defect on CAG. We performed additional ballooning, but the filling defect didn't change. However, the blood flow was not disturbed, and then we terminated the procedure. Final OCT image also demonstrated an intimal flap as shown in figure 1. Six months after PCI with DCA, a follow-up CAG was performed. CAG showed that the filling defect at the proximal stent edge in the LCX disappeared. OCT confirmed complete healing of the intimal flap (Figure 2).
We experienced a case that dissection after DCA was repaired in chronic phase. OCT clearly visualized healing of an intimal flap. Additional stenting to such a coronary dissection would be a usual procedure. However, this case suggests that additional stenting could be deferred in a case without coronary flow disturbance by an intimal flap.