Case Title
Treatment of instent restenosis
Case History
Instent Restenosis
This 48 yrs old lady had acute coronary syndrome in June 2003. She was stabilised with heparin, antiplatelet, beta-blocker and was then take up for angiography-SOS plasty at leading centre in Mumbai. Very tight LAD stenosis in the mid segment was observed and 3mm Taxus TM (Boston Scientific) Paclitaxel coated 16mm long stent.
In four months time she got readmitted at the same centre with unstable angina with anterior wall non Q wave myocardial infarction on ECG. She was stabilised with the use of Thrombolytic agent. The ECG got normalized immediately and patient discharged within one weak in reasonably comfortable state.
In one and half months time she was investigated by me at Lilawati Hospital. Angiography revealed severe restenosis in the distal one third of the stent and extending beyond the stent for few mm.
Discussion
Instent stenosis could be of 4 types
Type 1: Within the stent and focal (10mm or less). This best treated by high pressure balloon angioplasty, with reasonable success both short term and long term. One should be careful to restrain the balloon within the stent boundry. Watermelon seed observed frequently.
Type 2: Involves entire length of the stent.
Type 3: Extenteds on either boundry of the stent.
Type 4: Complete occlusion of the stent.
The immediate results and late outcome are unsatisfactory in the last two types. Recently few isolated studied have indicated good results with Drug Eluting Stent.
In our case negative factors was her LPA was 5 times the normal value (150 mg) Unfortunately this holds true irrespective of loosing any option-intervention or bypass.
We would be doing another angiography on her in 8 months time.
Investigation Reports
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Click on the thumbnail images to see the videos
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6F left voda 3 mm guide catheter in nicely fitting into left coronary ostium and angiography done. Shows good delination of the instent stenosis. |
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Shows the voda guide catheter engaged towards the circumflex as left main is short with early bifurcation. Attempts to entubate guide catheter into the LAD failed and the guidewire also could not be introduced in to the LAD inspite of the guide catheter withdrawal and giving more J to the guidewire. |
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6FL 3.5 cm Judkins guide catheter was taken and selectively engaged into LAD and radius floppy guidewire introduced in to LAD while crossing through the stent the guidewire was continuously rotated so that it does not get caught in to the struts of the stent. Direct stenting was done with 2.75*20mm Taxus Stent with some over lap. |
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Shows excellent result of direct stenting of instent stenosis. |
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Negotiating the odds in complicated lesions Mar 18, 2004
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An approach to an extremely tortuous RCA distal lesion Feb 11, 2004
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An approach to markedly tortuous lesion. Dec 24, 2003
Angioplasty standby for failed bypass surgery. Dec 2, 2003
Treatment of instent restenosis. Nov 15, 2003
Veingraft angioplasty with protection device. Nov 1, 2003
Complex angioplasty in tortuous vessels. Oct 16, 2003
Angioplasty & Stenting in tortuous vessels. Oct 1, 2003
60 yr. Old man with a History of Multiple Coronary Grafts Sep 15, 2003
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Courtesy
Dr. A.B. Mehta
Director Of Cardiology,
Jaslok Hospital,
Mumbai, India.
Website: http://www.drabmehta.com
Email: drabmehta@cardiovalens.com
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