“Cutting Balloon and the Three Burrs”: Treatment for Ostial Left Anterior Descending Artery In-Stent Restenosis

In-stent restenosis (ISR) is a difficult complication to treat, occurring in 15–35% of stents deployed for de novo lesions in native coronary arteries.1,2 The restenosis rate following therapy for ISR is as high as 54%.3 Thus far, there is conflicting evidence in the literature as to the most practical approach for treating in-stent restenosis. We report a case of a left anterior descending artery (LAD) ostial in-stent restenosis treated with a combination of rotational atherectomy and “cutting” balloon percutaneous transluminal coronary angioplasty (PTCA). Case Report. A 58-year-old male with post-infarct angina and a positive exercise test was referred for PTCA and stenting to his LAD, which had a 95% eccentric but discrete proximal lesion. The lesion was pre-dilated with a 3.0 x 9 mm Solaris® balloon (Guidant Corporation, Temecula, California), causing local dissection. A 3.5 x 16 mm NIR Royal® stent (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota) was deployed and post-dilated with the Solaris balloon at high pressure with a good result. Symptoms of angina had returned after 3 months and repeat angiography showed in-stent restenosis involving the ostium of the LAD coronary artery (Figure 1A). A 10 French (Fr) L Judkins 3.5 guide catheter was used and a 0.009´´ rotawire was passed into the distal LAD. Rotational atherectomy (Rotablator®, Boston Scientific/Scimed, Inc.) was performed using three successive burrs (1.5 mm, 2.0 mm and 2.5 mm) (Figures 1B and 1C). Significant angiographic improvement occurred by debulking the lesion, although a residual stenosis persisted (Figure 1D). A 3.5 x 10 mm “cutting” balloon (Barath®, Interventional Technologies IVT, Inc., San Diego, California) inflated at 9 atmospheres was then used to good effect (Figures 1E and 1F). The lesion was further dilated with an over-sized, short, 4.0 x 10 mm WorldPass® balloon (Cordis Corporation, Miami, Florida) with a perfect angiographic result (Figure 1G). The patient remained asymptomatic at 9-month follow-up exam, with normal exercise tolerance, although coronary angiography showed focal in-stent restenosis of less than 50% at the most proximal portion of the stent. Discussion. In-stent restenosis occurs in 15–35% of all stents deployed.1,2 The restenosis rate following therapy for ISR is as high as 85%.3 Various new technologies other than plain old balloon angioplasty (POBA) have been advocated for treating these lesions. Although emerging evidence favors the use of brachytherapy for ISR, it is not yet widely available and remains a costly and manpower-intensive procedure. There is conflicting evidence in the literature regarding which of the more readily available devices is the best treatment option for ISR. The use of rotational atherectomy (RA) is supported by the interim results of the ROSTER (Randomized Trial of Rotational Atherectomy vs. Balloon Angioplasty for In-Stent Restenosis) trial.4 This study showed that rotational atherectomy resulted in better luminal gain, lower incidence of stent use and lower clinical restenosis (20% vs. 43%; p = 0.01) compared to POBA. However, the results of the ARTIST (Angioplasty vs. Rotational Atherectomy for Treatment of Diffuse In-Stent Restenosis) trial did not favor RA.5 The event-free survival at 6 months was 91.1% for PTCA and 79.6% for RA (p = 0.005) and the angiographic restenosis rate was 51.2% for PTCA and 64.8% for RA (p = 0.04). Early results of non-randomized studies using cutting balloons for ISR show good immediate outcomes, although re-restenosis data are unavailable.6,7 The RESCUT (Restenosis Cutting Balloon Evaluation) and REDUCE 2 (Restenosis Reduction by Cutting Balloon Evaluation) studies should provide long-term re-restenosis rates in patients undergoing cutting balloon PTCA or POBA for restenosis. In situations such as ISR within a stent placed at the ostium of the LAD where the restenosis rate is high, it would not be unreasonable to combine two potentially useful techniques in the hope of obtaining a greater beneficial effect than with each individual procedure alone. This case demonstrates that rotational atherectomy and “cutting” balloon PTCA can be performed safely together and achieve an excellent acute result. However, the long-term benefit of combining these two technologies needs to be evaluated by a randomized trial.

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