Author + information
- Hiroyoshi Kawamoto, MD,
- Vasileios F. Panoulas, MD,
- Katsumasa Sato, MD,
- Tadashi Miyazaki, MD,
- Azeem Latib, MD and
- Antonio Colombo, MD∗ ()
- ↵∗EMO-GVM Centro Cuore Columbus, 48 Via M. Buonarroti, 20145 Milan, Italy
Diagnostic angiogram of a 66-year-old man presenting with stable angina revealed significant lesions in the left main coronary artery (LMCA) trifurcation and the left anterior descending artery (LAD) diagonal bifurcation (Figure 1). In the latter, after deployment of a 2.5 × 16.0 mm Promus element (Boston Scientific, Natick, Massachusetts) with mini-crush technique in the diagonal with initial kissing balloon inflation (KBI), a 3.0 × 18.0 mm ABSORB bioresorbable vascular scaffold (BVS) (Abbott Vascular, Santa Clara, California) was implanted in the proximal LAD without final KBI. In the LMCA trifurcation lesion, a 3.5 × 18.0 mm ABSORB BVS was implanted with single crossover technique, jailing the left circumflex and intermediate arteries. This was followed by deployment of a 3.5 × 15.0 mm Xience PRIME (Abbott Vascular) in the proximal to mid LMCA.
Coronary angiography and optical coherence tomography (OCT) (Ilumien Optis, St. Jude Medical, St. Paul, Minnesota) were performed at 24 months’ follow-up because of recurrent angina. Coronary angiography showed in-scaffold restenosis in the distal LMCA. OCT showed BVS struts previously jailing the side branch ostia to have completely disappeared in both bifurcation lesions. The fact that BVS struts were still visible on the wall of the distal LMCA but not over the ostia of the side branches could be explained by either a more rapid reabsorption of BVS in the free flowing bloodstream or bulk scaffold erosion and remnant embolization. Despite the absence of symptoms since the index procedure and a current angiogram showing Thrombolysis In Myocardial Infarction flow grade 3 with no evidence of distal emboli, sporadic embolization of small scaffold segments cannot be excluded. In the LAD bifurcation, BVS struts on top of the crushed metal struts have been completely covered with neointima (Figures 1B and 1D). In the LMCA lesion, OCT revealed late recoil of the BVS overlying an area of calcified plaque (1) with scaffold deformation and homogenous neointimal hyperplasia (Figures 1F to 1H).
Follow-up OCT images clearly revealed the mechanism of in-scaffold restenosis (combination of neointimal hyperplasia and late scaffold recoil) and provided further insight in the treatment of bifurcation lesions with the single crossover technique. Disappearance of BVS struts jailing the side branch ostia may reduce very late restenosis in this location and facilitate very late side branch access should new disease develop in the jailed vessel. This case also demonstrates the importance of meticulous lesion preparation with rotational atherectomy or scoring balloon in case of BVS implantation for calcified lesions.
Please note: Dr. Latib has served on advisory boards for Medtronic and has received a research grant from Angioscore. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation