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Drug-eluting stent as an option for intractable in-stent coronary restenosis.
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MedLine Citation:
PMID:  22194765     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
A 51-year-old man was admitted due to an acute anterior ST-segment elevation myocardial infarction. After thrombolytic therapy using recombinant tissue plasminogen activator, stent implantation was performed from the proximal left anterior descending artery (LAD) to the mid LAD using a bare-metal stent (BMS). Since then, the patient suffered five repeated episodes of in-stent restenosis (ISR). At the first ISR, he was treated with plain old balloon angioplasty (POBA). At the second ISR, he was treated with brachytherapy, and at the third ISR, he was treated with POBA and one more BMS distal to the previously implanted stent. At the forth, only POBA was performed, and finally, at the fifth ISR, a sirolimus-eluting stent was implanted. Following that, the patient remained asymptomatic and follow-up coronary angiography showed no ISR.
Authors:
Daisuke Hachinohe; Myung Ho Jeong; Min Chol Kim; Kyung Hoon Cho; Khurshid Ahmed; Seung Hwan Hwang; Min Goo Lee; Doo Sun Sim; Keun-Ho Park; Ju Han Kim; Young Joon Hong; Youngkeun Ahn; Jung Chaee Kang
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Publication Detail:
Type:  Journal Article     Date:  2011-11-29
Journal Detail:
Title:  Korean circulation journal     Volume:  41     ISSN:  1738-5555     ISO Abbreviation:  Korean Circ J     Publication Date:  2011 Nov 
Date Detail:
Created Date:  2011-12-23     Completed Date:  2012-10-02     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101247141     Medline TA:  Korean Circ J     Country:  Korea (South)    
Other Details:
Languages:  eng     Pagination:  677-80     Citation Subset:  -    
Affiliation:
The Heart Center of Sapporo Higashi Tokushukai Hospital, Sapporo, Japan.
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Full Text
Journal Information
Journal ID (nlm-ta): Korean Circ J
Journal ID (publisher-id): KCJ
ISSN: 1738-5520
ISSN: 1738-5555
Publisher: The Korean Society of Cardiology
Article Information
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Copyright © 2011 The Korean Society of Cardiology
open-access:
Received Day: 04 Month: 10 Year: 2010
Revision Received Day: 09 Month: 2 Year: 2011
Accepted Day: 16 Month: 2 Year: 2011
Print publication date: Month: 11 Year: 2011
Electronic publication date: Day: 29 Month: 11 Year: 2011
Volume: 41 Issue: 11
First Page: 677 Last Page: 680
ID: 3242025
PubMed Id: 22194765
DOI: 10.4070/kcj.2011.41.11.677

Drug-Eluting Stent as an Option for Intractable In-Stent Coronary Restenosis
Daisuke Hachinohe, MD12
Myung Ho Jeong, MD2
Min Chol Kim, MD2
Kyung Hoon Cho, MD2
Khurshid Ahmed, MD2
Seung Hwan Hwang, MD2
Min Goo Lee, MD2
Doo Sun Sim, MD2
Keun-Ho Park, MD2
Ju Han Kim, MD2
Young Joon Hong, MD2
Youngkeun Ahn, MD2
Jung Chaee Kang, MD2
1The Heart Center of Sapporo Higashi Tokushukai Hospital, Sapporo, Japan.
2The Heart Center of Chonnam National University Hospital, Gwangju, Korea.
Correspondence: Correspondence: Myung Ho Jeong, MD, The Heart Center of Chonnam National University Hospital, 671 Jeabong-ro, Dong-gu, Gwangju 501-757, Korea. Tel: 82-62-220-6243, Fax: 82-62-228-7174, myungho@chollian.net

Introduction

Stents reduce clinical and angiographic restenosis compared to conventional balloon angioplasty.1) However, in a number of patients with implanted stents, neointimal hyperplasia produces in-stent restenosis (ISR).2) Although often considered a benign process, recent data reveals that ISR has a negative impact on long-term survival.3) In fact, repeated procedures have been associated with a higher risk of myocardial infarction and stent thrombosis.4) Vascular brachytherapy was the approved therapy, in comparison with balloon angioplasty,5), 6) but recent studies suggest that drug-eluting stents (DES) may be superior to brachytherapy.7), 8) We experienced one intractable ISR case which repeated regardless of successful brachytherapy treatment, and which was treated using DES.


Case

On February 2000, a 51-year-old man was admitted to the hospital with an acute anterior ST-segment elevation myocardial infarction. His electrocardiogram (ECG) showed ST-segment elevation in V1-5. After thrombolytic therapy using recombinant tissue plasminogen activator, stent implantation was performed from the proximal left anterior descending artery (LAD) to the mid LAD using 3.0×27 mm bare-metal stent (BMS) as an elective percutaneous coronary intervention (Fig. 1).

One year later, recurrent chest pain developed and an ECG showed ST-segment elevations in V1-5. Coronary angiography (CAG) revealed type IV (total) ISR in the proximal LAD, which was treated with balloon angioplasty using a 3.0×20 mm balloon (the first ISR). One year after that, recurrent chest pain developed, and ECG showed no ST-T changes, but CAG revealed type II (diffuse) ISR. This second ISR was treated with brachytherapy with a Rhenium filled balloon (300 seconds at 6 atm using a 3.0×20 mm balloon) (Fig. 2).

Four months later, recurrent chest pain developed once again and an ECG showed ST-segment elevations in V1-4. CAG revealed type IV ISR secondary to brachytherapy failure, which was treated with 3.0×20 mm balloon and 3.0×18 mm BMS implantation distal to the previously implanted BMS (the third ISR) (Fig. 3). Three months later, chest pain recurred and ECG showed ST-segment elevations in V3-5. CAG revealed type II ISR, which was treated with only ballooning (the fourth ISR). Nine months later, recurrent chest pain developed, and ECG showed no ST-T changes. CAG revealed type II ISR in the proximal and mid LAD stent. A 3.0×33 mm Cypher stent® (Cordis Johnson & Johnson, Bridgewater, NJ, USA) was implanted to treat this fifth ISR presentation (Fig. 4). The patient then remained asymptomatic and the 5-year follow-up CAG showed no ISR (Fig. 5).


Discussion

Bare-mental stent has improved procedural success and long-term outcomes, and reduced clinical and angiographic restenosis compared to plain old balloon angioplasty (POBA).1), 9) Although stenting can resolve elastic recoil, negative remodeling and dissection caused by POBA and neointimal hyperplasia produces ISR in 20% to 50% of the patients implanted stent.2), 10) ISR is often considered to be a benign process, but a recent report showed that it presents with acute myocardial infarction or unstable angina in over one-third of cases3) and has a negative impact on long-term survival.11) In fact, repeated procedures have been associated with a higher risk of myocardial infarction and stent thrombosis.4)

There are many treatment options for ISR. Although POBA is the first-line option, its results have been disappointing. Repeated use of BMS also exacerbates the risk of recurrence. Coronary artery bypass surgery may be an option for the treatment of recurrent ISR after BMS implantation. Alternative options, such as rotational atherectomy, excimer laser angioplasty, and cutting balloon did not reduce recurrent ISR.12)

Several reports show the efficacy of brachytherapy in patients with ISR,5), 6), 13), 14) but brachytherapy presents problems such as logistical complexity, expense, and durability.12) Recent studies suggest that DES is superior to POBA,8), 15) and moreover DES may even be superior to brachytherapy.7), 8) This is a unique case for the successful management of intractable ISR with DES, even after POBA, BMS and brachytherapy.

In conclusion, we experienced an intractable ISR case, which can be treated by using DES. As recent studies show, DES is the best treatment option for ISR, and may even be used successfully to treat brachytherapy failure and intractable ISR.


Notes

The authors have no financial conflicts of interest.

References
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9. Fischman DL,Leon MB,Baim DS,et al. Stent Restenosis Study InvestigatorsA randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery diseaseN Engl J MedYear: 19943314965018041414
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Article Categories:
  • Case Report

Keywords: Drug-eluting stents, Coronary restenosis, Brachytherapy, Angioplasty.

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