The Difference Between Success and Failure: Subintimal Stenting Around an Occluded Stent for Treatment of a Chronic Total Occlusion Due to In-Stent Restenosis

Abstract: We present a case where conventional wire and equipment passage through the proximal cap of a chronic total occlusion due to in-stent restenosis was not possible. The lesion was then safely and successfully treated by deliberate passage into the subintimal space outside the previous stent with subsequent subintimal dissection and reentry into the true lumen beyond the occlusion. We then stented around the occluded stent, effectively crushing the previous stent in the true lumen and restoring flow by stenting open the new subintimal lumen. Follow-up angiography and optical coherence tomography at 6 months demonstrated good medium-term results.

J INVASIVE CARDIOL 2016;28(11):E136-E138

Key words: chronic total occlusion, in-stent restenosis, percutaneous coronary intervention

Case Presentation

A 60-year-old male presented with Canadian Cardiovascular Society class III/IV angina progressive over several years despite maximal medical therapy. He had previously undergone percutaneous coronary intervention (PCI) to a dominant right coronary artery (RCA). Coronary angiography demonstrated occlusion of the RCA with the proximal cap of the occlusion located proximal to the previous stent (Figure 1). 

A previous attempt to recanalize the RCA utilizing primarily antegrade wire escalation (AWE) had been unsuccessful. PCI was performed using a bifemoral approach and activated clotting time guided anticoagulation with heparin. An initial retrograde strategy was attempted, but was not possible due to poorly developed collaterals. The strategy was changed to AWE, but as before, it was extremely difficult to penetrate the proximal cap. A CrossBoss catheter (Boston Scientific) was considered, but could not be used as its success relies on penetrating the proximal cap of the occlusion to deliver the catheter into the stent.¹

Eventually using an anchor balloon inflated in the proximal vessel, a highly penetrative wire (15 g, ProVia; Medtronic) was advanced into the subintimal space outside the previous stent. The occluded segment was then traversed in the subintimal space using a Pilot 200 polymer wire (Abbott Vascular) and a Corsair catheter (Asahi Intecc) (Figure 2A). The true lumen was reentered in the distal vessel before the bifurcation using a Stingray balloon (Boston Scientific) and guidewire (Figure 2B). Two overlapping drug-eluting stents (Promus 2.5 x 38 mm and 3.0 x 38 mm; Boston Scientific) were subsequently deployed with a good final angiographic result (Figure 2C). Intravascular ultrasound demonstrated a subintimal tract length of approximately 60 mm; good apposition of the newly implanted stents with the previous (now crushed) stent was also visible (Figure 3).

Angiographic and optical coherence tomographic follow-up was performed at 6 months due to the unusual nature of revascularization; it demonstrated a durable result with endothelialization of all stent struts and no significant areas of malapposition (Figure 4). The patient is currently free of angina.

PCI for occlusive in-stent restenosis is challenging principally due to the highly resistant nature of the material that comprises the proximal cap. In cases where conventional techniques have failed, deliberate passage into the subintimal space outside the previously stented segment with subsequent distal reentry into the true lumen beyond the occlusion is safe, feasible, and may provide a successful strategy.

Reference

1.    Wilson WM, Walsh S, Hanratty C, et al. A novel approach to the management of occlusive in-stent restenosis (ISR). EuroIntervention. 2014;9:1285-1293.

From the ¹King’s College Hospital, London, United Kingdom; ²Edinburgh Heart Centre, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; ³Bristol Royal Infirmary, Bristol, United Kingdom; and ⁴Forth Valley Royal Hospital, Larbert, United Kingdom.

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 May 11, 2016, provisional acceptance given June 13, 2016, final acceptance given June 27, 2016.

Address for correspondence: James Roy, FRACP, Department of Cardiology, King’s College Hospital, Hambleden E Wing, Denmark Hill, London SE5 9RS, United Kingdom. Email: jamesroy@nhs.net