International Journal of Cardiology 177 (2014) e84–e86
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Follow-up evaluation of unapposed bioresorbable vascular scaffold at a coronary bifurcation using optical coherence tomography☆ E. Danson ⁎, R. Bhindi, P. Hansen Royal North Shore Hospital, Cardiology Dept., Reserve Road, St. Leonards, NSW 2065, Australia
a r t i c l e
i n f o
Article history: Received 30 September 2014 Accepted 1 October 2014 Available online 7 October 2014 Keywords: Bioresorbable vascular scaffold Optical coherence tomography PCI
The acute and long-term performance of bioresorbable scaffolds (BVS) in treating ostial or bifurcation coronary lesions has not been established. In particular, treatment of these lesions presents the potential problems of non-apposition of struts proximal to the ostium of the vessel or in side branches. Data is also lacking as to whether additional scaffolds can be delivered through struts into side branches for two stent approaches to bifurcations. Despite this there are very few reports of any adverse consequences resulting from their use in these lesions. Optical coherence tomography (OCT) has been used to follow up the appearances of BVS in coronary vessels revealing a reduction in the size and number of apparent struts to around 35% at 2 years [1]. There are also reports that neointimal growth from the vessel wall extends to cover non-apposed BVS struts across bifurcations [2]. We report a case of OCT follow-up of a BVS implanted across a bifurcation at 12 months previously revealing reduced non-apposed strut resorption but delivery of a further BVS through the unresorbed struts was uncomplicated. A 58 year old man with a dyslipidaemia presented with recurrent angina. He had undergone percutaneous intervention (PCI) with bioresorbable scaffold (BVS) implantation to his obtuse marginal (OM) coronary artery approximately 12 months beforehand. He had also undergone BVS implantation to his left anterior descending coronary artery (LAD) 15 months before representation. Angiography revealed a severe de novo lesion in the distal portion of the main circumflex vessel (see Fig. 1). Intracoronary imaging using optical co-
☆ This case report has not been previously published or submitted to this or any other journal. ⁎ Corresponding author. E-mail address: [email protected] (E. Danson).
http://dx.doi.org/10.1016/j.ijcard.2014.10.002 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
herence tomography (OCT) revealed patent scaffold in the LAD and OM with a discreet de novo stenosis in the circumflex (see Fig. 1). The proximal portion of the BVS in the OM extended into the main circumflex vessel. OCT revealed that these struts were larger with reduced resorption compared to the apposed struts in the OM (see Fig. 1). Twelve discreet segments of unapposed struts were clearly evident on OCT frames. We measured strut thickness and compared these to a random sample of twelve apposed struts evident on OCT. We found apposed strut thickness to be 110 ± 20 μm compared to unapposed 140 ± 10 μm (P b 0.05, unpaired t-test) which was not significantly different to the thickness of struts immediately following implantation (150 ± 10 μm). The BVS deployed in the LAD 15 months previously had struts of 90 + 20 μm. The de novo lesion was then predilated with a 2.25 mm balloon and a 2.5 × 12 mm BVS was delivered and deployed across the lesion without any problems. Post PCI imaging was satisfactory (see Fig. 1) and recovery uneventful. He has subsequently been symptom free for 6 months. Our case illustrates the follow-up appearances of unapposed BVS struts extending across the ostium of a coronary artery. In particular, the extent of resorption of unapposed struts appears reduced at 12 months compared to apposed struts. In addition, delivery of a 2.5 mm BVS was possible between the struts of the unapposed BVS after this interval without any obvious disruption evident on the post PCI OCT images. The long-term outcome of BVS implantation across coronary side branches is not known. However their use in this setting has been previously reported without any adverse outcomes. Data from exvivo bench testing have shown that the use of two BVS to cover complex bifurcation lesions is feasible [3] and cases of the successful use of BVS in culotte [4], provisional [5] and T-stenting [6] for bifurcations have been reported. However the appearance of the vessel after resorption of struts is yet to be determined and the impact of asymmetric resorption of the stent is not known. Early data suggests that intimal hyperplasia leads to contact and coverage of the unapposed scaffold in the longer term [2]. The appearances in our case are of possible formation of a tissue bridge across the vessel which may contribute to stable resorption over time. Whilst the appearance of unapposed struts across a side branch may seem unfavourable at 12 months, our case reveals no objective evidence of adverse outcome or anatomical impediment to further intervention. Conflict of interest We have no conflicts of interest to declare.
E. Danson et al. / International Journal of Cardiology 177 (2014) e84–e86
e85
Fig. 1. Angiography of the left coronary artery in the LAO (A) and RAO (B) caudal projections. The single arrow indicates the de novo lesion in the distal circumflex coronary. Both the LAD (double arrow) and obtuse marginal (triple arrow) reveal patent scaffold (implanted 15 and 12 months previously). Optical coherence tomography (OCT) images. The circumflex coronary artery reveals severe focal luminal narrowing (C). The obtuse marginal reveals patent scaffold with endothelisation (D). The left anterior descending (LAD) reveals a long segment of patent scaffold with evidence of overlapping struts (E). On pullback imaging of the circumflex coronary artery the wire and imaging catheter traverse scaffold struts extending from the obtuse marginal into the main proximal circumflex vessel (F, G). On pullback imaging of the obtuse marginal scaffold struts extending into the main circumflex have unapposed struts on both sides of the scaffold (H). Unapposed struts are thicker than apposed struts. Angiography post angioplasty using bioresorbable scaffold (BVS) in the circumflex (I) and OCT imaging of the BVS in the circumflex (J).
e86
E. Danson et al. / International Journal of Cardiology 177 (2014) e84–e86
References [1] Serruys PW, Ormiston JA, Onuma Y, Regar E, Gonzalo N, Garcia-Garcia HM, et al. A bioabsorbable everolimus-eluting coronary stent system (ABSORB): 2-year outcomes and results from multiple imaging methods. Lancet 2009;373(9667):897–910. [2] Gutiérrez-Chico JL, Gijsen F, Regar E, Wentzel J, de Bruyne B, Thuesen L, et al. Differences in neointimal thickness between the adluminal and the abluminal sides of malapposed and side-branch struts in a polylactide bioresorbable scaffold: evidence in vivo about the abluminal healing process. JACC Cardiovasc Interv 2012;5(4): 428–35. [3] Džavík V, Colombo A. The absorb bioresorbable vascular scaffold in coronary bifurcations: insights from bench testing. JACC Cardiovasc Interv 2014;7(1):81–8.
[4] Ruzsa Z, van der Linden M, Van Mieghem NM, Regar E, Ligthart JM, Serruys P, et al. Culotte stenting with bioabsorbable everolimus-eluting stents. Int J Cardiol 2013; 168(2):e35–7. [5] Grundeken MJ, Kraak RP, de Bruin DM, Wykrzykowska JJ. Three-dimensional optical coherence tomography evaluation of a left main bifurcation lesion treated with ABSORB® bioresorbable vascular scaffold including fenestration and dilatation of the side branch. Int J Cardiol 2013;168(3):e107–8. [6] Seth A, Sengottuvelu G, Ravisekar V. Salvage of side branch by provisional “TAP technique” using Absorb™ bioresorbable vascular scaffolds for bifurcation lesions: first case reports with technical considerations. Catheter Cardiovasc Interv 2014;84(1): 55–61.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Follow-up evaluation of unapposed bioresorbable vascular scaffold at a coronary bifurcation using optical coherence tomography☆ E. Danson ⁎, R. Bhindi, P. Hansen Royal North Shore Hospital, Cardiology Dept., Reserve Road, St. Leonards, NSW 2065, Australia
a r t i c l e
i n f o
Article history: Received 30 September 2014 Accepted 1 October 2014 Available online 7 October 2014 Keywords: Bioresorbable vascular scaffold Optical coherence tomography PCI
The acute and long-term performance of bioresorbable scaffolds (BVS) in treating ostial or bifurcation coronary lesions has not been established. In particular, treatment of these lesions presents the potential problems of non-apposition of struts proximal to the ostium of the vessel or in side branches. Data is also lacking as to whether additional scaffolds can be delivered through struts into side branches for two stent approaches to bifurcations. Despite this there are very few reports of any adverse consequences resulting from their use in these lesions. Optical coherence tomography (OCT) has been used to follow up the appearances of BVS in coronary vessels revealing a reduction in the size and number of apparent struts to around 35% at 2 years [1]. There are also reports that neointimal growth from the vessel wall extends to cover non-apposed BVS struts across bifurcations [2]. We report a case of OCT follow-up of a BVS implanted across a bifurcation at 12 months previously revealing reduced non-apposed strut resorption but delivery of a further BVS through the unresorbed struts was uncomplicated. A 58 year old man with a dyslipidaemia presented with recurrent angina. He had undergone percutaneous intervention (PCI) with bioresorbable scaffold (BVS) implantation to his obtuse marginal (OM) coronary artery approximately 12 months beforehand. He had also undergone BVS implantation to his left anterior descending coronary artery (LAD) 15 months before representation. Angiography revealed a severe de novo lesion in the distal portion of the main circumflex vessel (see Fig. 1). Intracoronary imaging using optical co-
☆ This case report has not been previously published or submitted to this or any other journal. ⁎ Corresponding author. E-mail address: [email protected] (E. Danson).
http://dx.doi.org/10.1016/j.ijcard.2014.10.002 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
herence tomography (OCT) revealed patent scaffold in the LAD and OM with a discreet de novo stenosis in the circumflex (see Fig. 1). The proximal portion of the BVS in the OM extended into the main circumflex vessel. OCT revealed that these struts were larger with reduced resorption compared to the apposed struts in the OM (see Fig. 1). Twelve discreet segments of unapposed struts were clearly evident on OCT frames. We measured strut thickness and compared these to a random sample of twelve apposed struts evident on OCT. We found apposed strut thickness to be 110 ± 20 μm compared to unapposed 140 ± 10 μm (P b 0.05, unpaired t-test) which was not significantly different to the thickness of struts immediately following implantation (150 ± 10 μm). The BVS deployed in the LAD 15 months previously had struts of 90 + 20 μm. The de novo lesion was then predilated with a 2.25 mm balloon and a 2.5 × 12 mm BVS was delivered and deployed across the lesion without any problems. Post PCI imaging was satisfactory (see Fig. 1) and recovery uneventful. He has subsequently been symptom free for 6 months. Our case illustrates the follow-up appearances of unapposed BVS struts extending across the ostium of a coronary artery. In particular, the extent of resorption of unapposed struts appears reduced at 12 months compared to apposed struts. In addition, delivery of a 2.5 mm BVS was possible between the struts of the unapposed BVS after this interval without any obvious disruption evident on the post PCI OCT images. The long-term outcome of BVS implantation across coronary side branches is not known. However their use in this setting has been previously reported without any adverse outcomes. Data from exvivo bench testing have shown that the use of two BVS to cover complex bifurcation lesions is feasible [3] and cases of the successful use of BVS in culotte [4], provisional [5] and T-stenting [6] for bifurcations have been reported. However the appearance of the vessel after resorption of struts is yet to be determined and the impact of asymmetric resorption of the stent is not known. Early data suggests that intimal hyperplasia leads to contact and coverage of the unapposed scaffold in the longer term [2]. The appearances in our case are of possible formation of a tissue bridge across the vessel which may contribute to stable resorption over time. Whilst the appearance of unapposed struts across a side branch may seem unfavourable at 12 months, our case reveals no objective evidence of adverse outcome or anatomical impediment to further intervention. Conflict of interest We have no conflicts of interest to declare.
E. Danson et al. / International Journal of Cardiology 177 (2014) e84–e86
e85
Fig. 1. Angiography of the left coronary artery in the LAO (A) and RAO (B) caudal projections. The single arrow indicates the de novo lesion in the distal circumflex coronary. Both the LAD (double arrow) and obtuse marginal (triple arrow) reveal patent scaffold (implanted 15 and 12 months previously). Optical coherence tomography (OCT) images. The circumflex coronary artery reveals severe focal luminal narrowing (C). The obtuse marginal reveals patent scaffold with endothelisation (D). The left anterior descending (LAD) reveals a long segment of patent scaffold with evidence of overlapping struts (E). On pullback imaging of the circumflex coronary artery the wire and imaging catheter traverse scaffold struts extending from the obtuse marginal into the main proximal circumflex vessel (F, G). On pullback imaging of the obtuse marginal scaffold struts extending into the main circumflex have unapposed struts on both sides of the scaffold (H). Unapposed struts are thicker than apposed struts. Angiography post angioplasty using bioresorbable scaffold (BVS) in the circumflex (I) and OCT imaging of the BVS in the circumflex (J).
e86
E. Danson et al. / International Journal of Cardiology 177 (2014) e84–e86
References [1] Serruys PW, Ormiston JA, Onuma Y, Regar E, Gonzalo N, Garcia-Garcia HM, et al. A bioabsorbable everolimus-eluting coronary stent system (ABSORB): 2-year outcomes and results from multiple imaging methods. Lancet 2009;373(9667):897–910. [2] Gutiérrez-Chico JL, Gijsen F, Regar E, Wentzel J, de Bruyne B, Thuesen L, et al. Differences in neointimal thickness between the adluminal and the abluminal sides of malapposed and side-branch struts in a polylactide bioresorbable scaffold: evidence in vivo about the abluminal healing process. JACC Cardiovasc Interv 2012;5(4): 428–35. [3] Džavík V, Colombo A. The absorb bioresorbable vascular scaffold in coronary bifurcations: insights from bench testing. JACC Cardiovasc Interv 2014;7(1):81–8.
[4] Ruzsa Z, van der Linden M, Van Mieghem NM, Regar E, Ligthart JM, Serruys P, et al. Culotte stenting with bioabsorbable everolimus-eluting stents. Int J Cardiol 2013; 168(2):e35–7. [5] Grundeken MJ, Kraak RP, de Bruin DM, Wykrzykowska JJ. Three-dimensional optical coherence tomography evaluation of a left main bifurcation lesion treated with ABSORB® bioresorbable vascular scaffold including fenestration and dilatation of the side branch. Int J Cardiol 2013;168(3):e107–8. [6] Seth A, Sengottuvelu G, Ravisekar V. Salvage of side branch by provisional “TAP technique” using Absorb™ bioresorbable vascular scaffolds for bifurcation lesions: first case reports with technical considerations. Catheter Cardiovasc Interv 2014;84(1): 55–61.
