Author + information
- Received April 12, 2016
- Accepted April 22, 2016
- Published online August 8, 2016.
- Judit Karacsonyi, MDa,b,
- Barbara Anna Danek, MDa,
- Aris Karatasakis, MDa,
- Imre Ungi, MDb,
- Subhash Banerjee, MDa and
- Emmanouil S. Brilakis, MD, PhDa,∗ ()
- aVA North Texas Healthcare System and UT Southwestern Medical Center, Dallas, Texas
- bDivision of Invasive Cardiology, Second Department of Internal Medicine and Cardiology Center, University of Szeged, Szeged, Hungary
- ↵∗Reprint requests and correspondence:
Dr. Emmanouil S. Brilakis, Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, Texas 75216.
A 79-year-old man was referred for percutaneous coronary intervention of a diffusely diseased and calcified right coronary artery lesion (Figure 1A). After orbital atherectomy and pre-dilation with a 2.5 mm balloon the right coronary artery was stented with two 2.75 mm drug-eluting stents that could not be expanded (Figures 1B and 1C), despite multiple, high-pressure (20 to 28 atm) balloon inflations with and without a buddy wire (arrowhead, Figure 1C). Excimer laser atherectomy (ELCA) was performed with a 0.9 mm catheter (Spectranetics, Colorado Springs, Colorado) using maximal pulse frequency of 80 Hz and maximal fluency of 80 mJ/mm2 without success. ELCA was repeated with simultaneous contrast injection, leading to stent expansion (Figure 1D), as confirmed by intravascular ultrasonography (Figure 1E) and optical coherence tomography (Figure 1F).
Stent underexpansion can predispose to in-stent restenosis and stent thrombosis (1). ELCA is usually performed during intracoronary saline infusion to minimize the risk for vapor bubble formation that can lead to arterial dissection (2). However, if ELCA fails to expand an underexpanded stent, activation with simultaneous contrast injection can create a powerful accousticomechanical effect that can lead to stent expansion. ELCA with simultaneous contrast injection should be used infrequently and with great caution, using only small (0.9 mm) catheters to minimize the risk for intracoronary bubble formation (1).
Dr. Banerjee has received research grants from Boston Scientific, Gilead, and The Medicines Company; has received consultant/speaker honoraria from Covidien, Medtronic, and Merck; and owns stock in MDCARE Global and intellectual property in HygeiaTel. Dr. Brilakis has received consulting/speaker honoraria from Abbott Vascular, Asahi, Cardinal Health, Elsevier, GE Healthcare, and St. Jude Medical; has received research support from Boston Scientific and InfraRedx; and has a spouse who is an employee of Medtronic. All other authors have confirmed that they have no relationships relevant to the contents of this paper to disclose.
- Received April 12, 2016.
- Accepted April 22, 2016.
- American College of Cardiology Foundation