Four-Layer Stent Sandwich for Recurrent In-Stent Occlusion of the Right Coronary Artery: "The Four Musketeers" Fighting for Coronary Flow

J INVASIVE CARDIOL 2018;30(10):E109-E110.

Key words: cardiac imaging, chronic total occlusion, optical coherence tomography

A 70-year-old man with a history of two successfully treated in-stent chronic total occlusions (IS-CTO) of the ostial right coronary artery (RCA) using drug-eluting stents presented with typical angina. Coronary angiography confirmed recurrent third episode of the late IS-CTO without retrograde filling of the distal RCA (Figure 1A). In contrast, coronary computed tomography angiography revealed a widely patent distal segment of the target RCA (Figure 1B). Successful recanalization of the RCA was performed using a Fielder FC coronary wire (Abbott/Asahi Intecc) (Figure 2A) and optical coherence tomography (OCT) demonstrated restenotic tissue and strut malapposition (Figures 2B and 2C, Video 1). Following predilation, three drug-eluting stents were implanted from ostial to distal RCA. After postdilation, TIMI grade 3 flow was achieved with four layers of stent struts visible on OCT (Figures 2D and 2E, Video 2). During 15-month follow-up, the patient remained asymptomatic.

In our case, intracoronary imaging with OCT revealed strut malapposition of previously implanted drug-eluting stents as the most plausible causative factor of recurrent IS-CTO. This highlights the potential utility of comprehensive OCT imaging for correcting stent failure.

View Video Series here. 

From the ¹Medical University of Warsaw, Warsaw, Poland; and ²Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland.

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 accepted May 3, 2018. 

Address for correspondence: Dr Maksymilian P. Opolski, Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland. Email: opolski.mp@gmail.com