Rotational Atherectomy Combined With Bioresorbable Vascular Scaffold Implantation: A Feasible Approach for Recurrent In-stent Restenosis When Other Therapies Failed

Abstract: The optimal treatment for recurrent in-stent restenosis (ISR) is uncertain. Everolimus-eluting bioresorbable vascular scaffold (BVS) use has been reported in a few cases as an interesting alternative, as it avoids long-term metal exposure to coronary circulation. Nevertheless, the underlying neointima and the multiple layers of previously implanted stents with underexpanded struts may contribute to recurrent ISR following BVS placement. We describe a feasible combined treatment for recurrent ISR in 2 patients using neointimal debulking and ablation of underexpanded stents by rotational atherectomy followed by BVS implantation. This conceptually attractive approach has not yet been reported.

J INVASIVE CARDIOL 2015;27(7):E143-E145

Key words: bioresorbable vascular scaffold, recurrent in-stent restenosis, rotational atherectomy

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Several approaches have been proposed for in-stent restenosis (ISR) treatment, including plain old balloon angioplasty, cutting or scoring balloon, stent-in-stent therapy with new-generation drug-eluting stent (DES), drug-eluting balloon, or coronary artery bypass grafting, but the optimal strategy is still uncertain.¹ Everolimus-eluting bioresorbable vascular scaffold (BVS) (Absorb; Abbott Vascular) use for recurrent ISR has been reported in a few cases.^2-6 The BVS is an interesting alternative, because it may avoid long-term metal exposure to the coronary circulation.^2,3 Nevertheless, the underlying neointima and the multiple layers of previously implanted stents with underexpanded struts may contribute to recurrent ISR following BVS implantation.^3,7

We describe a feasible unreported approach in 2 cases of recurrent ISR treated with neointimal debulking and ablation of underexpanded stents by rotational atherectomy (RA) followed by BVS implantation. Patients signed informed consent forms before the intervention.

Case #1

A 73-year-old hypertensive and dyslipidemic male had been treated with bare-metal stent (BMS) implantation in the right coronary artery (RCA) 5 years ago. Since then, he had multiple percutaneous coronary interventions due to symptomatic recurrent ISR, which were treated with: DES; cutting balloon and BMS; cutting balloon and two DESs; and drug-eluting balloon. Currently, he underwent coronary angiography for stable angina and inferior ischemia. ISR with total occlusion in the RCA and areas of stent underexpansion were depicted on angiography (Figures 1A, 1B, and 1C). After passing the wire across the lesion with the support of a microcatheter, RA with a 1.5 mm burr was performed (Figures 1B and 1C). The lesion was further prepared with a cutting balloon and non-compliant balloon inflation (3.5 x 15 mm at 24 atm) (Figure 1D). A 3.5 x 12 mm BVS was finally implanted with good final angiographic result (Figure 1E). No procedural complications occurred and at 7-month follow-up exam, the patient was asymptomatic with no evidence of residual ischemia. 

Case #2

 A 56-year-old diabetic male with previous triple coronary artery bypass graft surgery underwent angioplasty of the RCA using a BMS 12 years ago, due to occlusion of the saphenous graft to the RCA and evidence of inferior ischemia. Since then, ISR was treated with in-stent DES placement and recurrent ISR was treated with drug-eluting balloon. Currently, he presented with stable angina and inferior ischemia. The angiography revealed a long ISR with a pattern II⁷ in the RCA and stent underexpansion (Figure 2A). RA with a 1.5 mm burr was performed, followed by high-pressure balloon inflation (3.0 x 20 mm at 24 atm) and a 3.0 x 28 mm BVS was implanted uneventfully with good final angiographic result (Figures 2B, 2C, and 2D). At 8-month follow-up exam, the patient was asymptomatic with no evidence of inferior ischemia. 

Discussion

BVS usage has been described in a few cases of recurrent ISR.^2-6 It combines vessel scaffolding and antirestenotic drug delivery in the short term, while avoiding long-term exposure of metal struts to coronary circulation, reducing the trigger for neointimal proliferation.^2,3 However, it is still a matter of placing a stent over neointimal hyperplasia and multiple stent layers, which are responsible for ISR.³ In fact, in a small series of 25 patients with 30 ISR lesions treated with BVS, the target lesion revascularization rate was 8.0% at a median of 7 months of follow-up.³

Although intracoronary imaging was not performed in our patients, the angiographic signs of stent underexpansion in segments with multiple stent layers and the multiple instances of ISR suggest that underexpansion was the mechanical trigger for neointimal proliferation and ISR.^1,8 RA ablates in-stent neointima, creating a greater minimal luminal diameter with less tissue extrusion through the struts, although the results of this approach have been inconsistent.^9-11 RA has also been successfully used for stent ablation of unexpanded stents.¹² In our patients previously treated with multiple stents, the RA may have ablated the luminal protruding struts of the unexpanded stents. The increased luminal area allowed further optimization with a cutting balloon in case #1 and the high-pressure balloon inflations may have contributed to expand the previous stents in both cases. Finally, the treated segment was scaffolded with a BVS. At short-term to medium-term follow-up, the clinical outcome was good. Although this conceptually attractive approach has not been compared with other treatment options, it has shown to be feasible and effective, deserving future long-term comparative studies.

Conclusion

We describe a feasible combined treatment for recurrent ISR using RA followed by BVS implantation. This approach has not previously been reported.

References

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From the Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted July 22, 2014, provisional acceptance given August 11, 2014, final version accepted September 8, 2014.

Address for correspondence: Dr Tiago Pereira-da-Silva, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Department of Cardiology, Rua de Santa Marta, n^o 50, Lisbon, Portugal 1169-024. Email: tiagopsilva@sapo.pt