Author + information
- Received January 23, 2017
- Accepted February 9, 2017
- Published online March 29, 2017.
- Giuliana Capretti, MDa,
- Satoru Mitomo, MDa,
- Manuela Giglio, MDb,
- Mauro Carlino, MDa,
- Antonio Colombo, MDa and
- Lorenzo Azzalini, MD, PhD, MSca,∗ ()
- aDivision of Interventional Cardiology, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
- bCardiovascular Disease Prevention Center (CPC), San Raffaele Scientific Institute, Milan, Italy
- ↵∗Address for correspondence:
Dr. Lorenzo Azzalini, Division of Interventional Cardiology, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy.
- chronic total occlusion
- in-stent restenosis
- intravascular ultrasound
- multidetector computed tomography
- optical coherence tomography
A 46-year-old man underwent percutaneous coronary intervention with a drug-eluting stent on the distal right coronary artery. Six years later, he was diagnosed with in-stent chronic total occlusion of the right coronary artery causing inferior-wall ischemia, and was scheduled for percutaneous coronary intervention.
The occlusion was long, with an ambiguous proximal cap, and interventional epicardial collateral channels from the circumflex (Figure 1A). An antegrade true-to-true attempt failed to cross the lesion, therefore a retrograde approach was undertaken. A Sion guidewire (Asahi Intecc, Nagoya, Japan) over a Corsair microcatheter (Asahi Intecc) was successfully advanced across the lesion and into the antegrade guiding catheter (Figure 1B). It was later noticed that the wire crossed the occlusion completely outside stent, through the subintimal space (Figure 1C). The decision was taken to crush the occluded stent and to implant a new drug-eluting stent in the subintimal space (Figure 1D). Three additional overlapping drug-eluting stents were subsequently deployed with good angiographic result (Figure 1E).
Two months later, coronary angiography (Figures 2A and 2B), multidetector computed tomography (Figures 2C and 2D), intravascular ultrasound, and optical coherence tomography (Figure 2E) were performed, showing persistent optimal result in the right coronary artery and particularly at the site of subintimal crush of the occluded stent. The patient remained asymptomatic throughout follow-up.
Although in-stent chronic total occlusion is usually recanalized using a true-to-true lumen approach (1), subintimal crush of the occluded stent represents an alternative strategy. Invasive imaging in this setting is useful to confirm optimal crush of the occluded stent, and good expansion and apposition of the newly implanted stent in the subintimal space (2).
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 23, 2017.
- Accepted February 9, 2017.
- 2017 American College of Cardiology Foundation
- Azzalini L.,
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