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Failure of drug-coated balloon angioplasty to treat bare metal in-stent restenosis accompanied by late stent thrombosis but successful treatment of binary in-stent restenosis.

ABSTRACT: Drug-coated balloons (DCB) are effective in treating in-stent restenosis (ISR) with neointimal proliferation after bare-metal stent (BMS) implantation, but it is unclear whether DCB are effective in treating BMS-ISR accompanied by thrombosis. An 84-year-old man with previous inferior myocardial infarction and atrial fibrillation developed acute myocardial infarction (AMI) during hospitalization for intracerebral hemorrhage. Emergent coronary angiography (CAG) revealed severe stenosis of the distal left circumflex coronary artery. We implanted a BMS to avoid long-term triple antithrombotic therapy. He received aspirin, clopidogrel, and rivaroxaban for 1 month and then received clopidogrel and rivaroxaban. Seventy days after BMS implantation, he developed AMI, and emergent CAG revealed occlusion of the BMS due to late stent thrombosis. After thrombus aspiration, intravascular ultrasound showed incomplete neointimal healing in the proximal portion of the stent and excessive neointimal proliferation in the distal portion of the stent. DCB angioplasty of the entire BMS was performed after scoring balloon pre-dilation. Seven months after BMS implantation, follow-up CAG revealed binary ISR. DCB angioplasty of the entire BMS was performed again after scoring balloon pre-dilation. Thirteen months after BMS implantation, follow-up CAG did not reveal recurrence of ISR. .

SUBMITTER: Shimizu T

PROVIDER: S-EPMC6718827 | biostudies-other | 2019 Sep

REPOSITORIES: biostudies-other

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Failure of drug-coated balloon angioplasty to treat bare metal in-stent restenosis accompanied by late stent thrombosis but successful treatment of binary in-stent restenosis.

Shimizu Takuya T Obata Jun-Ei JE Umetani Ken K Kugiyama Kiyotaka K

Journal of cardiology cases 20190516 3

Drug-coated balloons (DCB) are effective in treating in-stent restenosis (ISR) with neointimal proliferation after bare-metal stent (BMS) implantation, but it is unclear whether DCB are effective in treating BMS-ISR accompanied by thrombosis. An 84-year-old man with previous inferior myocardial infarction and atrial fibrillation developed acute myocardial infarction (AMI) during hospitalization for intracerebral hemorrhage. Emergent coronary angiography (CAG) revealed severe stenosis of the dist ...[more]

PMID: 31497171

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Project description:The purpose of this article was to compare the efficiency and safety of drug-coated balloon angioplasty (DCB) and atherectomy with percutaneous transluminal angioplasty (PTA) in patients with femoropopliteal in-stent restenosis (ISR). Pubmed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) (all up to March 2019) were searched systematically. Trial sequential analysis (TSA) was conducted. 5 studies with 599 participants were included. Compared with PTA, DCB significantly increased the rate of patency (6 months: RR 1.65, 95% CI 1.30 to 2.09, P < 0.01; 12 months: RR 2.38, 95% CI 1.71 to 3.30, P < 0.01) and the rate freedom from target lesion revascularization (TLR) (6 months: RR 1.18, 95% CI 1.09 to 1.28, P < 0.01; 12 months: RR 1.56, 95% CI 1.33 to 1.82, P < 0.01) at 6 and 12 months follow-up, and the TSA results showed these outcomes were reliable. The rate of clinical improvement by ≥1 Rutherford category in the DCB group was higher than that in the PTA group (6 months: RR 1.35, 95% CI 1.03 to 1.75, P = 0.03; 12 months: RR 1.46, 95% CI 1.17 to 1.82, P < 0.01) at 6 and 12 months. There is no statistically difference of ABI, all-cause mortality, and incidence of amputation between DCB group and PTA group (MD 0.03, 95% CI -0.03 to 0.08, P = 0.40; RR 1.24, 95% CI 0.46 to 3.34, P = 0.67; RR 0.32, 95% CI 0.01 to 7.61, P = 0.48). Compared with PTA, the rate of patency and freedom from TLR in the laser atherectomy (LD) group was higher than that in the PTA group (patency: 6 months: RR 1.28, 95% CI 1.01 to 1.64, P < 0.05, 12 months: RR 2.25, 95% CI 1.14 to 4.44, P < 0.05; freedom from TLR: 6 months: RR 1.27, 95% CI 1.05 to 1.53, P = 0.01, 12 months: RR 1.59, 95% CI 1.12 to 2.25, P = 0.01) at 6 and 12 months follow-up. In conclusion, DCB and LD had superior clinical (freedom from TLR and clinical improvement) and angiographic outcomes (patency rate) compared with PTA for the treatment of femoropopliteal ISR. Moreover, DCB and LD had a low incidence of amputation and mortality and were relatively safe methods.

Project description:BackgroundDrug-coated balloon angioplasty after directional coronary atherectomy (DCA) allows for a stentless strategy providing good short-term outcomes; however, late-phase restenosis and its mechanism remain unclear. Moreover, histopathological evaluation for late-phase restenosis post-drug-coated balloon angioplasty after DCA has never been reported.Case summaryWe report the first case of late-phase restenosis post-drug-coated balloon angioplasty after DCA, wherein tissue analysis using intravascular coronary imaging and histopathology suggested neovascularization in newly developed neointimal proliferation. A 52-year-old man with a history of dyslipidaemia presented with exertional angina pectoris. He underwent percutaneous coronary intervention (PCI) with drug-coated balloon angioplasty after DCA for the proximal left anterior descending artery. Although coronary angiography after nine months revealed no restenosis, he experienced recurrent chest discomfort after 25 months. Coronary angiography confirmed late-phase restenosis, and intravascular ultrasound showed progressively developed neointima above the underlying residual plaque. Optical coherence tomography suggested developing neovascularization within the neointima. Stentless PCI with drug-coated balloon angioplasty after DCA was re-performed, and collected restenotic sample. The histopathological evaluation confirmed less-cellular neointimal proliferation with rich neovascularization and concomitant diffuse vascular endothelial growth factor (VEGF) expression.DiscussionLate-phase restenosis post-drug-coated balloon angioplasty after DCA comprised less-cellular neointima, suggesting inhibition of cell proliferation by drug-coated balloon efficacy. However, diffuse VEGF expression and concomitant rich neovascularization with haemorrhage and inflammation might indicate neointimal proliferation. Further large-scale investigations of the restenotic mechanism should be performed to avoid long-term target vascular failure after drug-coated balloon angioplasty post-DCA.

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Failure of drug-coated balloon angioplasty to treat bare metal in-stent restenosis accompanied by late stent thrombosis but successful treatment of binary in-stent restenosis.

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Failure of drug-coated balloon angioplasty to treat bare metal in-stent restenosis accompanied by late stent thrombosis but successful treatment of binary in-stent restenosis.

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