OCT ASSESSMENT OF CUTTING BALLOON ANGIOPLASTY FOR IN-STENT RESTENOSIS

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1 OCT ASSESSMENT OF CUTTING BALLOON ANGIOPLASTY FOR IN-STENT RESTENOSIS Division of Cardiology, Mount Sinai Hospital, New York, NY, USA Yuliya Vengrenyuk, PhD; and Annapoorna Kini, MD

2 OCT ASSESSMENT OF CUTTING BALLOON ANGIOPLASTY FOR IN-STENT RESTENOSIS CLINICAL HISTORY A 57-year-old male with hyperlipidemia, controlled hypertension, and controlled noninsulin-dependent diabetes mellitus (NIDDM) presented with CCS class IV angina. The patient had multiple previous drug-eluting stent (DES) percutaneous coronary interventions (PCI). The last PCI was done 9 months earlier in the mid RCA and proximal LAD. PROCEDURE Coronary angiogram showed 90-95% diffuse in-stent restenosis of the Promus Premier stent, which had been implanted in the RCA 9 months earlier (Figure 1A, arrow). The lesion was first treated using a 4 6 mm Flextome Cutting Balloon (CB) inflated to 12 atm (Figure 1B); then, an optical coherence tomography (OCT) pullback was performed to assess the effects of CB angioplasty. Figure 1. Coronary angiography shows severe in-stent restenosis in the mid RCA before (A, arrow) and after cutting balloon angioplasty (B). A B 2 OCT ASSESSMENT OF CUTTING BALLOON ANGIOPLASTY FOR IN-STENT RESTENOSIS

3 Figure 2. OCT/angiography after cutting balloon angioplasty. After the CB procedure, OCT detected irregular lumen surface with several intimal fissures and flaps (Figure 2, frames 3 and 4). A long intimal flap was detected in the OCT longitudinal view (Figure 2, top, arrow) and frame 3 (arrows). Minimal lumen area was 6.26 mm 2 suggesting effective plaque scoring. A thin layer of neointima was detected at the proximal and distal stent edge (Figure 2, 2 and 5). OCT showed a small calcification proximal to the stent (Figure 2, 1) and large circumferential calcification distal to the stent (Figure 2, 6, asterisks); no calcium deposits were detected inside the stent. Two original stent layers were visualized by OCT imaging (inserts in Figure 2, 2 and 4). OCT ASSESSMENT OF CUTTING BALLOON ANGIOPLASTY FOR IN-STENT RESTENOSIS 3

4 Figure 3. OCT/angiography co-registration imaging after stent placement. Based on the preprocedural evaluation of lesion morphology and CB effects, a Xience Xpedition stent DES 4 20 mm was deployed. OCT/angiogram pullback after the new stent placement shown in Figure 3 confirmed good stent expansion and apposition (2), detected a small tissue protrusion (3), didn t detect stent edge dissections (1,4-6). CONCLUSIONS In-stent restenosis (ISR) after PCI remains one of the major clinical problems in the DES era. Treatment of ISR lesions includes conventional percutaneous transluminal coronary angioplasty (PTCA) or CB angioplasty with or without restenting. In this case, we used OCT/angiography co-registration imaging to analyze the effects of cutting balloon angioplasty and evaluate the characteristics of in-stent restenosis lesion. The decision to put another stent was made based on OCT detection of a large intimal flap after cutting balloon. Post-PCI OCT imaging was used to verify new stent expansion and apposition. 4 OCT ASSESSMENT OF CUTTING BALLOON ANGIOPLASTY FOR IN-STENT RESTENOSIS

5 Rx Only Brief Summary: Prior to using these devices, please review the Instructions for Use for a complete listing of indications, contraindications, warnings, precautions, potential adverse events and directions for use. Promus Premier, Flextome Cutting Balloon and Xience Xpedition are trademarks of Boston Scientific Corporation or its affiliates. Unless otherwise noted, indicates that the name is a trademark of, or licensed to, St. Jude Medical or one of its subsidiaries. ST. JUDE MEDICAL and the nine-squares symbol are trademarks and service marks of St. Jude Medical, Inc. and its related companies St. Jude Medical, Inc. All Rights Reserved. St. Jude Medical Inc. Global Headquarters One St. Jude Medical Drive St. Paul, MN USA T F St. Jude Medical S.C., Inc. Americas Division 6300 Bee Cave Road Bldg. Two, Suite 100 Austin, TX USA T F SJM Coordination Center BVBA The Corporate Village Da Vincilaan 11-Box F1 B-1935 Zaventem, Belgium T F St. Jude Medical Brasil Ltda. Rua Itapeva, 538 5º ao 8º andares São Paulo SP Brazil T F St. Jude Medical (Hong Kong) Ltd. Suite 1608, 16/F Exchange Tower 33 Wang Chiu Road Kowloon Bay, Kowloon Hong Kong SAR T F St. Jude Medical Japan Co., Ltd. Shiodome City Center 15F Higashi Shinbashi, Minato-ku Tokyo Japan T F St. Jude Medical Australia Pty, Ltd. 17 Orion Road Lane Cove, NSW 2066 Australia T F SJMprofessional.com SJM-OPS a This document is for international use only.

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