A Palmaz-Schatz Stent was Partially Resected by Directional Coronary Atherectomy Device to Treat a Stent-Jailed Side Branch

It has been reported that the percutaneous coronary intervention (PCI) for bifurcation lesions results in a much higher restenosis rate than that for non-bifurcation lesions.^1,2 Moreover, stent implantation to bifurcation lesions often causes side branch occlusion or narrowing, mainly due to the plaque shift from the parent vessel and/or the ostium being compromised by the stent struts themselves.³ Yet another problem is that stenting at a bifurcation lesion might impair accessibility to newly developed stenosis of a side branch, especially when a slotted tube stent is implanted at a previous PCI, a situation generally called “stent jail.” However, owing to the refinement of stent design — not only coil stents but also many slotted tube stents — excellent side branch accessibility is now possible. Consequently, problem PCI cases with regard to stent jail have become rare these days. The Palmaz-Schatz stent, a first generation stent, is composed of three closed-cell segments connected by two spiral link segments. Because of these structural characteristics, it is almost impossible to fully expand side branches when their orifices are covered by the closed-cell segment. Theoretically, the diameter of a fully dilated single cell of a Palmaz-Schatz stent would only be 2.5 mm, which is not large enough for highly developed side branches. Herein, we describe a case with coronary stenoses at a stent-jailed side branch six years after the patient’s first PCI, when a Palmaz-Schatz stent was implanted to treat a parent vessel stenosis. In order to obtain full access to the stent-jailed side branch and to treat the distal stenoses, we decided to partially abrade the stent struts by using a directional coronary atherectomy (DCA) device. Case report. Three Palmaz-Schatz stents (spiral type, Johnson and Johnson) had been implanted into the left anterior descending coronary artery (LAD) and the left circumflex coronary artery (LCX) of a male patient to treat his angina pectoris six years ago. He was admitted to our hospital complaining of newly developed chest pain. Treadmill exercise test showed significant ST-segment depression accompanying anginal chest pain. Moreover, echocardiography revealed hypokinesis at the posterior-lateral left ventricular wall, which was not observed at the previous echocardiographic examination. Coronary angiography (CAG) revealed two severe stenoses at the distal LCX which branched from the stented segment, while there was no restenosis at the three previously stented segments (Figure 1). DCA was planned to resect the stent struts and treat these complex lesions. We succeeded in crossing a guidewire into the distal LCX through the stent struts. The stent struts that jailed the side branch were fully dilated by a non-compliant balloon (Power Sail 2.5 x 15 mm, Guidant) with 18 atm (Figure 2A). A Multi-Link Plus stent (2.5 x 15 mm, Guidant Corp., Santa Clara, Calif.) was successfully delivered through the dilated stent struts, and deployed at the distal stenosis (Figure 2B). After recrossing the 0.014 inches Flexiwire guidewire (Guidant) throughout the previously implanted Palmaz-Schatz stent of the parent LCX, an atherectomy catheter (Flexicut-L, Guidant) was advanced within the Palmaz-Schatz stent. Under fluoroscopic guidance, an atherectomy window was carefully positioned to face toward the stent jailed side branch covering the proximal one-third of the Palmaz-Schatz stent. Then the atherectomy was carried out 7 times and balloon inflation pressure was gradually increased (10 to 40 psi) to resect the stent struts. Very thin metal fragments were detected in the materials retrieved from the nosecone of Flexicut. Fluoroscopy clearly showed that the stent struts had been partially removed by DCA (Figures 3 A and B). An additional Multi-Link Penta stent (3.0 x 18 mm, Guidant) was then deployed at the bifurcation lesion, followed by simultaneous kissing balloon technique to settle the configuration of both Multi-Link Penta and Palmaz-Schatz stents. Post-procedural CAG revealed optimal dilatation of side branch stenoses without change in themorphology of the parent vessel or the configuration of the originally implanted Palmaz-Schatz stent (Figure 4). Neither creatine-kinase leakage nor ST-segment changes on electrocardiogram were observed after the procedure. Medication with b-blocker, nitrates, aspirin and Ca antagonist was continued, and the patient was discharged one week post-operatively. Discussion. DCA has been shown to provide a very low restenosis rate compared with simple stenting when aggressive debulking is performed with the guidance of intravascular ultrasound.^4,5 DCA may have an advantage over the conventional PCI procedure using balloon and stent, especially in cases with complex coronary lesions, such as ostial LAD stenosis, bifurcation lesion and in-stent restenosis.^6–8 The second generation DCA device equipped with a titanium cutting blade has superb capability to resect atheroma plaques. In our experience, the Flexicut has even proved capable of abrading calcified lesions in some selected cases. It was reported that DCA happened to resect stent struts when used for in-stent restenoses.⁹ Based on this evidence, PCI was chosen for this case. Surgical back-up was indispensable for this case because there was a possibility of the DCA device getting stuck within a partially abraded Palmaz-Schatz stent, a scenario which has been previously reported.⁹ There were a few reports in which rotational atherectomy device was used to abrade a stent strut to obtain side branch accessibility.¹⁰ However, to the best of our knowledge, this is the first case report to show that a DCA device can be used to salvage a stent-jailed side branch stenosis. In summary, this case suggests that DCA could be a powerful tool to overcome stent jail and to obtain full access to side branches for additional or future PCI procedures if such procedures become necessary.

1. Yamashita T, Nishida T, Adamian MG, et al. Bifurcation lesions: Two stents versus one stent: Immediate and follow-up results. J Am Coll Cardiol 2000;35:1145–1151. 2. Kastrati A, Mehilli J, Dirschinger J, et al. Intracoronary stenting and angiographic results: Strut thickness effect on restenosis outcome (ISAR-STEREO) trial. Circulation 2001;103:2816–2821. 3. Iniguez A, Macaya C, Alfonso F, et al. Early angiographic changes of side branches arising from a Palmaz-Schatz stented coronary segment: Results and clinical implications. J Am Coll Cardiol 1994;23:911–915. 4. Suzuki T, Hosokawa H, Katoh O, et al. Effects of adjunctive balloon angioplasty after intravascular ultrasound-guided optimal directional coronary atherectomy: The result of adjunctive balloon angioplasty after coronary atherectomy study (ABACAS). J Am Coll Cardiol 1999;34:1028–1035. 5. Tsuchikane E, Sumitsuji S, Awata N, et al. Final results of the STent versus directional coronary Atherectomy Randomized Trial (START) J Am Coll Cardiol 1999;34:1050–1057. 6. Airoldi F, Di Mario C, Stankovic G, et al. Clinical and angiographic outcome of directional atherectomy followed by stent implantation in de novo lesions located at the ostium of the left anterior descending coronary artery. Heart 2003;89:1050–1054. 7. Karvouni E, Di Mario C, Nishida T, et al. Directional atherectomy prior to stenting in bifurcation lesions: A matched comparison study with stenting alone. Cathet Cardiovasc Interven 2001;53:12–20. 8. Sanchez PL, Rodriguez-Alemparte M, Colon-Hernandez PJ, et al. Directional coronary atherectomy vs. rotational atherectomy for the treatment of in-stent restenosis of native coronary arteries. Cathet Cardiovasc Interven 2003;58:155–161. 9. Haberbosch W, Waas W, Waldecker B, et al. Directional coronary atherectomy of in-stent restenosis: A two-center experience. J Interven Cardiol 2000;13:93–100. 10. Abdelmeguid AE. New technique for stent jail: Another niche for the Rotablator. Cathet Cardiovasc Diagn 1997;42: 321–324.