Coronary CT Angiography for In-Stent Restenosis: Diagnosis and Therapeutic Planning

J INVASIVE CARDIOL 2017;29(6):E71.

Key words: cardiac imaging, in-stent restenosis

A 64-year-old man presented with previous non-ST elevation myocardial infarction and cardiogenic shock. At that time, coronary angiography showed mid and distal left main (LM), ostial left anterior descending (LAD), and ostial left circumflex (LCX) severe stenosis as well as proximal right coronary chronic total occlusion. Due to hemodynamic instability, percutaneous coronary intervention (PCI) was performed with implantation of two everolimus-eluting stents by V-stenting technique (3.0 x 24 mm and 3.0 x 32 mm Promus Premier stents [Boston Scientific] to the LM-LAD and LM-LCX, respectively).  

After 9 months without symptoms, he developed progressive angina. Non-selective LM coronary angiography was performed due to stent protrusion in the aortic root; it showed doubtful lesion in the LM. A 128-slice dual-source coronary computed tomographic angiography (Somatom definition flash; Siemens) was performed to confirm the presence of the lesion; it evidenced severe LM-LAD stent underexpansion with critical in-stent restenosis at the proximal third (Figure 1A).

Two days later, selective angiography and optical coherence tomography (ImageWire-Lightlab Imaging) depicted stent underexpansion (Figure 1B) and confirmed the in-stent restenosis. Two overlapping 3 x 20 mm non-compliant NC-Trek balloons (Abbott Vascular) were deployed in the underexpanded LM-LAD and LM-LCX, respectively, and final kissing balloon was performed with paclitaxel-eluting 3 x 20  mm SeQuent-Please balloon (Braun) in the LM-LAD and 3 x 12  mm non-compliant NC-Trek balloon in the LM-LCX. Excellent final results were demonstrated by angiographic and optical coherence tomography (Figure 1C).

This case illustrates the potential role of the complementary use of invasive and non-invasive imaging techniques. Coronary computed tomography angiography was very useful to identify the severity and mechanism of restenosis, and thus guided the PCI procedure in a case of especially difficult catheterization.

From the ¹Cardiology and ²Radiology Departments, Hospital Universitario Central de Asturias, Oviedo, Spain.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Morís reports proctor and advisory board fees from Medtronic. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript submitted October 11, 2016, provisional acceptance given October 17, 2016, final version accepted October 26, 2016.

Address for correspondence: José Rozado, MD, Área del Corazón, Hospital Universitario Central de Asturias, Avda de Roma s/n, Oviedo, España. Email: joserozadocast@gmail.com