Author + information
- Received May 7, 2015
- Accepted May 23, 2015
- Published online November 1, 2015.
- Hiroyoshi Kawamoto, MD∗,†,
- Neil Ruparelia, DPhil∗,†,‡,
- Filippo Figini, MD∗,†,
- Azeem Latib, MD∗,† and
- Antonio Colombo, MD∗,†∗ ()
- ∗Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
- †Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
- ‡Department of Cardiology, Imperial College, London, United Kingdom
- ↵∗Reprint requests and correspondence:
Dr. Antonio Colombo, EMO-GVM Centro Cuore Columbus, 48 Via M. Buonarroti, Milan 20145, Italy.
- bioresorbable scaffold
- coronary bifurcation
- optical frequency domain imaging
- percutaneous coronary intervention
- T-stenting and small protrusion technique
A 53-year-old man presenting with stable angina underwent coronary angiography demonstrating a critical true bifurcation lesion (Medina 1,1,1) of the left anterior descending coronary artery (LAD) (Figure 1A) (1). Following pre-dilation, a 3.5 × 18-mm Absorb (Abbott Vascular, Santa Clara, California) bioresorbable scaffold (BRS) was implanted in the LAD with subsequent 3.5-mm high-pressure noncompliant balloon post-dilation. However, due to the compromise of the side-branch ostium (Figure 1B), a 3.0 × 12-mm Absorb BRS was implanted using the T-stenting and small protrusion (TAP) technique (Figure 1C), following side-branch pre-dilation with 2.5-mm balloon. Post-implantation intravascular ultrasound (IVUS) revealed asymmetric expansion of the main branch as a result of the neoplastic carina with overlapping BRS struts (Figures 2A and 2B). Follow-up angiography at 14 months, performed for recurrent angina, demonstrated severe in-scaffold restenosis of the main branch (Figure 2A′). Optical frequency domain imaging (OFDI) (LUNAWAVE, Terumo Corporation, Tokyo, Japan) following pre-dilation with a 2.0-mm balloon demonstrated large-volume neointimal hyperplasia of the neoplastic carina (Figure 2I, 2A′–2B′). To effectively treat this lesion, a 3.5 × 18-mm metallic sirolimus-eluting stent (Ultimaster, Terumo Corporation) was implanted into the main branch but was complicated by side-branch occlusion (Figure 1B′). A further 3.0 × 15-mm Ultimaster stent was implanted into the side branch using the TAP technique (Figure 1C′). Subsequent OFDI demonstrated a compressed neoplastic carina with plaque protrusion (Figure 2B′) and a shortened neoplastic carina compressed by the newly fashioned neometallic carina (Figure 2II).
BRS are increasingly being used to treat complex lesions, and the long-term outcome following implantation in bifurcation lesions is unknown. In this case, the resultant long neoplastic carina following implantation of 2 BRS may have resulted in aggressive neointimal hyperplasia at this site. When BRS are considered for the treatment of bifurcation lesions, meticulous procedural techniques that minimize strut protrusion into the main branch should be employed to optimize clinical outcomes.
Dr. Latib has served on the advisory board of Medtronic; and has received honoraria from Boston Scientific and Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 7, 2015.
- Accepted May 23, 2015.
- American College of Cardiology Foundation