BVS disrup#on at LCx os#um: OCT findings at 6-‐months

BVS disrup+on at LCx os+um: OCT findings at 6-­‐months follow-­‐up Toru Naganuma1,2 Azeem La2b2, Alaide Chieffo2, Sunao Nakamura1, Antonio Colombo2 1. New Tokyo Hospital, Chiba, JAPAN 2. San Raffaele Science Ins2tute and　EMO-­‐GVM Centro Cuore Columbus, Milan, ITALY Case
•  59-­‐year-­‐old male •  Chest pain on effort •  Coronary risk factors: HTN, family history of CAD •  LVEF: 50%
PCI
previously implanted DES BVS 3.5 x 12mm 3.5mm NC balloon Pre-­‐dila2on: 3.0mm NC balloon ➜ ABSORB BVS 3.5 x 12mm (Abbo[ Vascular, Santa Clara, California) ➜ Post-­‐dila2on: 3.5mm OPN NC® balloon (SIS Medical AG, Winterthur, Switzerland) (presumed balloon diameter: 3.85mm at 30atm.)
Final CAG Severe restenosis at LCx os+um at 6 months OCT failed due to +ght restenosis
2.0mm balloon OCT retry
•  Gentle pre-­‐dila2on with a 2.0 mm balloon was performed as the 2ght restenosis did not allow adequate contrast flush to assess OCT images. Post-­‐procedure
A
At 6-­‐month
LADpreviously implanted DES
B
LAD
Small SB
3.5x12mm BVS
LCx
C D E F G H
C’D’E’F’G’
H’
I
F
J LAD
LM
C
H
Small SB
LM
I
D
LCx
overlapping struts LAD
F’
no struts
LCx
C D E F G
I’
LCx
C’ D’ E’F’G’
E
C’
neo-­‐carina
D’
neo-­‐carina
J’
H’
I’
E’
overlapping struts
LAD
SD: 3.03/3.14mm SA: 7.45mm2 G
H
I
Small SB
LAD
G’
overlapping struts
SD: 2.26/2.71mm SA: 5.01mm2 H’
Small SB
I’
Disrup+on!!
F
F’ no struts overlapping struts
Why disrupted??
Ques+on-­‐1: Overexpansion?? ➜ NO!! •  One of the poten2al causes for BVS disrup2on is stent overexpansion, which should be avoided as BVS distensibility is up to 0.5mm (0.7mm?). •  However, this was not the cause in this case, as we chose an appropriate sized (3.5mm) non-­‐compliant balloon for post-­‐dila2on (presumed balloon diameter: 3.85mm for a 3.5mm BVS) and confirmed no evidence of BVS overexpansion or disrup2on at post-­‐procedural OCT. Ques+on-­‐2: anatomical problem of LCx os+um? MITO (MIlan-­‐new TOkyo) registry Background
•  PCI of distal unprotected LMCA is usually performed by sten2ng from LMCA to the LAD. •  However, in certain situa2ons, single-­‐stent crossover technique from LMCA to the LCx is performed. LAD
LMCA
stent
LCx
•  There is scarcity of data on the outcome with this strategy. •  We aim to report long-­‐term clinical outcome with this technique in our cohort.
High restenosis rate at LCx os+um even aZer sten+ng towards LCx
Restenosis at LCx os+um aZer sten+ng towards LCx
LAD
LMCA
*
restenosis
LCx
LAD
LMCA
*restenosis
LCx
Restenosis at LAD os+um aZer sten+ng towards LAD
Discussion
•  Hinge point of acute angula2on •  1st genera2on DES: 81.8% (Cypher: 54.5%, closed cell) torsion, flexion and rota2onal forces → stent fa2gue and rupture → restenosis…
LMCA
LCx
LMCA
LCx
LMCA-­‐LCx: Cypher 3.5× 33mm, 34 months later
Ques+on-­‐2: anatomical problem? ➜ Probably yes!! acute angula+on
LAD
Disrup+on at LCx os+um!
LMCA
LCx
hinge mo+on Conclusions The os2um of lek circumflex artery may remain the Achilles’s heel of PCI.