A Challenging Case of Bifurcation Lesion in Left Anterior Descending Artery: Managed Successfully with Everolimus-Eluting Bioresorbable Vascular Scaffold and Kissing Balloon Technique under Optical Coherence Tomography Guidance

Sridhar Kasturi; Shivakumar Bandimida; Nirlep Gajiwala; Ashok Thakkar

doi:10.4103/2321-449X.157280

CASE REPORT

Year : 2015 | Volume : 3 | Issue : 3 | Page : 79-81

A Challenging Case of Bifurcation Lesion in Left Anterior Descending Artery: Managed Successfully with Everolimus-Eluting Bioresorbable Vascular Scaffold and Kissing Balloon Technique under Optical Coherence Tomography Guidance

Sridhar Kasturi¹, Shivakumar Bandimida¹, Nirlep Gajiwala², Ashok Thakkar²
¹ Department of Cardiology, Sunshine Heart Institute, Secunderabad, Hyderabad, Telangana, India
² Department of Clinical Research and Medical Writing, Sahajanand Medical Technologies Pvt. Ltd., Surat, Gujarat, India

Date of Web Publication

7-Sep-2015

Correspondence Address:
Dr. Sridhar Kasturi
Department of Cardiology, Sunshine Heart Institute, Paradise SD Road, Secunderabad - 500 003, Hyderabad, Telangana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2321-449X.157280

Abstract

A 54-year-old Indian male patient was presented to our hospital with the complaints of chest pain since 1-day prior to admission. He was diagnosed, elsewhere, with anterior-wall myocardial infarction and was treated with tenecteplase. Subsequently, he was referred to us for the management of postinfarction angina. He was a known case of hypertension and had no family history of coronary artery disease. Echocardiogram demonstrated hypokinesia of anterolateral wall with normal left ventricular function. Angiography revealed a single vessel disease-99% stenosis in the mid-segment of left anterior descending (LAD) coronary artery with significant narrowing at the proximal site of diagonal 1 (D1) branch. An optical coherence tomography-guided percutaneous coronary intervention to the LAD-D1 bifurcation lesion was performed successfully using ABSORB bioresorbable vascular scaffold (Abbott Vascular, USA) and kissing balloon angioplasty. No postprocedural complication was observed and the patient was discharged the next day. Clinical evaluation at 1-year follow-up was satisfactory.

Keywords: Angiography, balloon angioplasty, bioresorbable vascular scaffold, coronary artery disease, kissing balloon, optical coherence tomography

How to cite this article:
Kasturi S, Bandimida S, Gajiwala N, Thakkar A. A Challenging Case of Bifurcation Lesion in Left Anterior Descending Artery: Managed Successfully with Everolimus-Eluting Bioresorbable Vascular Scaffold and Kissing Balloon Technique under Optical Coherence Tomography Guidance. Heart India 2015;3:79-81

How to cite this URL:
Kasturi S, Bandimida S, Gajiwala N, Thakkar A. A Challenging Case of Bifurcation Lesion in Left Anterior Descending Artery: Managed Successfully with Everolimus-Eluting Bioresorbable Vascular Scaffold and Kissing Balloon Technique under Optical Coherence Tomography Guidance. Heart India [serial online] 2015 [cited 2023 May 31];3:79-81. Available from: https://www.heartindia.net/text.asp?2015/3/3/79/157280

Introduction

Left anterior descending (LAD) artery is considered a high-risk lesion with restenosis approaching nearly 50% after percutaneous coronary intervention (PCI). ^[1] Implantation of stents becomes challenging, particularly in patients with bifurcation lesion in the LAD branch due to high risk of subacute thrombosis, restenosis and side-branch damage. ^[2],[3] Management of such lesions with bioresorbable vascular scaffold (BVS) and kissing balloon technique (KBT) are not reported previously. Here, we present a complex case of hypertensive patient with anterior-wall myocardial infarction having a single vessel disease-LAD bifurcation lesion-treated with a BVS and kissing balloon angioplasty under optical coherence tomography (OCT)-guidance.

Case Report

A 54-year-old Indian male was presented and admitted to our hospital with the complaints of chest pain since morning 1-day prior to admission. He was diagnosed, elsewhere, with anterior-wall myocardial infarction and was treated with intravenous tenecteplase. Poststabilization, the patient was referred to our hospital for further investigation of postinfarction angina. The patient was a known case of hypertension, with no other significant past illness. On admission, he was hemodynamically stable and exhibited normal left ventricular function. The pulse rate was 94/min and the blood pressure was 140/100 mmHg. The cardiovascular examination revealed S1 ⁺ , S2 ⁺ , S3 ⁰ , S4 ⁰ , with no other significant finding. All laboratory findings were within normal limits. Further, the history of coronary artery disease was not evident in patient's family.

The patient underwent two-dimensional echocardiography (Phillips Medical Systems, USA), which demonstrated anterolateral wall hypokinesis. The ejection fraction was 60%. Coronary angiography was performed, which revealed a single vessel disease to LAD with 99% stenosis in the mid segment [Figure 1]a. A considerable narrowing in proximal diagonal 1 (D1) branch was also evident. Calcification was not observed in the lesions. The patient was advised to undergo PCI with a BVS system to LAD and plain old balloon angioplasty to D1 under OCT guidance using KBT.

Figure 1: (a) Mid LAD 99% lesion (arrow) and significant narrowing in proximal D1 branch; (b) Deployment of BVS to the mid LAD with KBT (arrow); (c) Good flow in the LAD post-PCI; (d-f) Postprocedural OCT showing well-opposed struts (LAD: Left anterior descending; D; Diagonal branch; PCI: Percutaneous coronary intervention; KBT: Kissing balloon technique; OCT: Optical coherence tomography; BVS: Bioresorbable vascular scaffold)

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Percutaneous coronary intervention was performed via the right radial approach with a 6Fr guide catheter (Boston Scientific, USA). The left main coronary artery was engaged with XB 3.0Fr guiding catheter. The LAD lesion was crossed with the balance-middle-weight guidewire (Abbott Vascular, USA) while the D1 lesion was crossed with Sion blue wire (Abbott Vascular, USA). Predilatation was performed with 2.0 mm × 9 mm Maverick balloon (Boston Scientific, USA) and Mini Trek balloon (Abbott Vascular, USA) in the LAD and D1 lesions respectively. Then LAD-D1 kissing balloon angioplasty was initiated using 2.5 mm × 14 mm Falcon balloon (Medtronic Inc., USA) in the LAD and 2.0 mm × 09 mm Maverick balloon (Boston Scientific, USA) in the D1. At this point, the angiogram revealed well-dilated D1 and LAD with mild residual narrowing of LAD. Subsequently, a 3.5 mm × 28 mm ABSORB BVS (Abbott Vascular, USA), an everolimus-eluting scaffold, was implanted in mid LAD at 16 atm, a pressure not beyond the rated burst pressure, for 22 s and was redilated at 16 atm for 30 s. After scaffold deployment, postdilatation was performed with 3.5 mm × 12 mm Trek NC balloon (Abbott Vascular, USA) at 14 atm. Then, the jailed Sion blue wire was replaced with another Sion blue wire (Abbott Vascular, USA) to re-enter the D1 lesion. Finally, the LAD-D1 kissing balloon angioplasty was completed with 3.5 mm × 12 mm Trek NC (Abbott Vascular, USA) in LAD and 2.0 mm × 09 mm Maverick balloon (Boston Scientific, USA) in D1 [Figure 1]b. Thus, a successful OCT-guided PCI was completed with ABSORB BVS using kissing method for the LAD-D1 bifurcation lesion [Figure 1]c. Postprocedural OCT (St. Jude Medical, USA) demonstrated well-opposed stent struts [Figure 1]d-f. The final coronary angiogram revealed good thrombolysis in myocardial infarction (TIMI) III flow (TIMI grade flow). Patient was discharged on 2 ^nd day of PCI after an uneventful hospital stay. Postdischarge, the patient was under regular clinical follow-up and showed no cardiovascular symptoms with excellent exercise capacity at the end of 1-year.

Discussion

Treatment of bifurcation lesion is always a challenging task in context of complexity and complications involved. In this regard, several methods have been developed; KBT is one of them. ^[3] Despite oldest, kissing balloon inflation is the most widely used method for percutaneous bifurcation interventions in current practice. It improves the PCI outcomes by optimizing stent apposition, correcting stent deformation, and improving side branch access. ^[3] A recent meta-analysis also favored that simple one-stent strategy along with a kissing balloon method offers similar clinical outcomes as compared to complex strategy of stenting both branches. ^[4] Accordingly, we opted for the management of bifurcation lesion with single BVS and kissing balloon inflation under OCT guidance in our case. We opine that OCT not only offers accurate visualization of the internal anatomy of lesion and precise estimation of the lesion size, but also helps evaluating the integrity of the scaffold, its apposition to the underlying wall, presence of thrombus, and changes in the strut characteristics over time after the implantation. Previous studies have already established that the rate of strut malapposition significantly reduced when OCT was used in treating a bifurcation lesion. ^[5],[6]

Apart from the interventional technique, the choice of stent also plays an important role. Despite the well-established efficacy of drug-eluting stents in improving PCI outcomes, it is pondered that the scaffolding function of the stent is no longer required once the target-vessel has healed. This consideration has led to the evolution of BVS, which are able to provide mechanical support for particular period in the initial stages followed by complete absorption from the vessel, leading to natural healing of the lesion with minimal risk of stent thrombosis. ^[7] Although the safety and efficacy of the everolimus-eluting BVS is reported in patients with simple lesions, ^[8],[9] clinical experience of these scaffolds is limited in patients with complex lesions, including those with bifurcation lesions, as such patients were excluded from the trials. In the present singe-case study, we report successful management of bifurcation lesion with ABSORB BVS system using the KBT in a patient with anterior-wall myocardial infarction. To the best of our knowledge, this is the first Indian report of the successful management of bifurcation lesion using a single BVS. The procedural and postprocedural outcomes were satisfactory in our patients.

References

1.	O′Keefe JH Jr, Kreamer TR, Jones PG, Vacek JL, Gorton ME, Muehlebach GF, et al. Isolated left anterior descending coronary artery disease: Percutaneous transluminal coronary angioplasty versus stenting versus left internal mammary artery bypass grafting. Circulation 1999;100 19 Suppl:II114-8.
2.	Brett S, Gunn J. Images in cardiology. Shotgun stenting of the left main coronary artery bifurcation. Heart 2006;92:310.
3.	Sgueglia GA, Chevalier B. Kissing balloon inflation in percutaneous coronary interventions. JACC Cardiovasc Interv 2012;5:803-11.
4.	Niccoli G, Ferrante G, Porto I, Burzotta F, Leone AM, Mongiardo R, et al. Coronary bifurcation lesions: To stent one branch or both? A meta-analysis of patients treated with drug eluting stents. Int J Cardiol 2010;139:80-91.
5.	Alegría-Barrero E, Foin N, Chan PH, Syrseloudis D, Lindsay AC, Dimopolous K, et al. Optical coherence tomography for guidance of distal cell recrossing in bifurcation stenting: Choosing the right cell matters. EuroIntervention 2012;8:205-13.
6.	Viceconte N, Tyczynski P, Ferrante G, Foin N, Chan PH, Barrero EA, et al. Immediate results of bifurcational stenting assessed with optical coherence tomography. Catheter Cardiovasc Interv 2013;81:519-28.
7.	Gonzalo N, Macaya C. Absorbable stent: Focus on clinical applications and benefits. Vasc Health Risk Manag 2012;8:125-32.
8.	Onuma Y, Serruys PW, Ormiston JA, Regar E, Webster M, Thuesen L, et al. Three-year results of clinical follow-up after a bioresorbable everolimus-eluting scaffold in patients with de novo coronary artery disease: The ABSORB trial. EuroIntervention 2010;6:447-53.
9.	Nakatani S, Onuma Y, Ishibashi Y, Muramatsu T, Iqbal J, Zhang YJ, et al. Early (before 6 months), late (6-12 months) and very late (after 12 months) angiographic scaffold restenosis in the ABSORB Cohort B trial. EuroIntervention 2015;10:1288-98.