International Journal of Cardiology 190 (2015) 99–101
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Treating and healing coronary artery ectasia disease with Bioresorbable Vascular Scaffold Kuan Leong Yew Cardiology Department, Sarawak General Hospital Heart Center, Kota Samarahan, 94300 Sarawak, Malaysia
a r t i c l e
i n f o
Article history: Received 16 April 2015 Accepted 18 April 2015 Available online 21 April 2015 Keywords: Coronary artery ectasia Coronary artery aneurysm Bioresorbable vascular scaffold ABSORB Negative remodeling Fractional flow reserve
Coronary artery ectasia (CAE) disease is closely associated with atherosclerosis and coronary artery disease. In CAE, the affected coronary segment is enlarged and dilated to at least 1.5 times the diameter of the relatively normal adjacent coronary [1,2]. There is abnormality of coronary artery remodeling in CAE with atherosclerotic disease [2]. Therefore, it is worthwhile to report a case treated with bioresorbable vascular scaffold (BVS) (Abbott Vascular, Santa Clara, USA) which was shown to heal the coronary stenosis and reversed the abnormal coronary artery remodeling process in CAE. A 56-year-old man with dyslipidemia had 1 year history of atypical chest pain. The exercise treadmill test was inconclusive and the cardiac computed tomography angiography (CCTA) showed ectasia disease of the coronaries and an eccentric tight lesion prior to the beginning of an ectatic segment in the right coronary artery (RCA) (Fig. 2A, C). Thus, he underwent an elective transradial coronary angiography study. It showed large ectatic segments at the prox–mid-RCA and distal RCA with a preceding eccentric lesion (Fig. 1A, B, C), ectatic prox–midleft anterior descending artery followed by small caliber of the remaining LAD and mild ectasia of the left circumflex artery. The optical coherence tomography (OCT) confirmed the eccentric narrowing prior to the beginning of a big ectatic distal segment of the RCA (Fig. 1E). Fractional flow reserve (FFR) demonstrated a value of 0.76 at maximal hyperemia. We proceeded to perform transradial percutaneous coronary intervention (PCI). The lesion was predilated with E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2015.04.150 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
a 3.0 × 15 mm semi-compliant balloon. A 3.5 × 28 mm BVS was positioned at the mid–distal RCA with the distal part of the BVS covering the eccentric lesion site and slightly encroaching into the proximal segment of the distal coronary ectasia (Fig. 1D). The BVS was postdilated with a 4.0 × 8 mm non-compliant balloon. Postdilatation OCT showed adequate coverage of the eccentric lesion site with no geographical miss and generally well apposed scaffolds (Fig. 1F). The patient remained well and the 18 month follow-up CCTA showed the disappearance of the eccentric lesion and mild late lumen gain of the treated RCA segment (Fig. 2B, D). PCI in a coronary artery affected by an ectatic or aneurysmal segment is technically challenging in view of the luminal diameter discrepancy, tapering shape and vessel wall contour irregularity. The application of conventional balloon-expandable metallic stents seemed to be an ill-fitting solution for these atypical coronary anatomies. Overzealous stent expansion in order to chase the eventual size of the ectatic segment may result in coronary dissection, hematoma or perforation. Underexpansion of the tubular metallic stent would lead to the higher risk of stent strut malapposition and stent thrombosis [3–6]. With the advent and availability of self-apposing stents such the STENTYS (STENTYS SA, Paris, France) stent, it gave much hope and reassurance in dealing with the unmet needs in the treatment of CAE. In the real world setting, self-apposing STENTYS stents have been used successfully for the treatment of variable coronary ectasia and aneurysmal disease, saphenous vein graft and acute coronary syndrome [6–8]. The initial technical success and short term result seemed favorable thus far. STENTYS is made from nitinol and nickel–titanium alloy with selfexpanding property. However, this is also a type of metallic stent which is permanently implanted in the coronary artery. Hence, it would be beneficial if we can implant a stent with drug eluting property to treat the initial coronary disease in CAE and “disappear” after the completion of the job without the worry of long term risk of stent malapposition and stent thrombosis. Everolimus-eluting BVS can prevent coronary restenosis and restore coronary vasomotion with late luminal enlargement and eventual freedom from permanent metallic caging of the coronaries. BVS is completely resorbed after 2–3 years and the risk of scaffold thrombosis is gone too. The BVS was carefully positioned under fluoroscopic guidance to ensure minimal scaffold protrusion into the post-stenotic ectatic segment and avoid geographical miss of the eccentric lesion. Too much scaffolding of the ectatic segment would increase the probability of scaffold malapposition and acute thrombosis risk. Lately, there have been
100
K.L. Yew / International Journal of Cardiology 190 (2015) 99–101
Fig. 1. Coronary angiography showing the eccentricity of the lesion (black arrow) which was complicated by a large post-stenotic ectatic distal right coronary artery (RCA) segment (A–C). A 3.5 × 28 mm BVS was deployed from the mid-RCA to distal ectatic segment (D). Optical coherence tomography (OCT) demonstrated the significant narrowing (black arrow) and ectatic nature of the RCA (E). OCT showed that the BVS was well expanded and well apposed to the vessel wall (F).
some signals about BVS associated scaffold malapposition and coronary aneurysm [9,10]. Scaffolding of the ectatic segment could have inadvertently accentuated the positive remodeling process, further luminal enlargement and worsened the luminal discrepancy. The relatively small caliber mid–distal RCA segment could have been afflicted by the negative remodeling pathology of CAE. The BVS was shown to reverse this process and increased the lumen size as evidenced by the 18 month follow-up CCTA. Thus, BVS should be avoided or minimized in a big ectatic segment to prevent excessive positive remodeling and luminal enlargement, and may be applied in a narrow tubular segment to reverse the inherent negative remodeling process. The key towards the successful application of BVS in this atypical coronary anatomy was the adequate lesion preparation with balloon predilatation and intracoronary imaging with OCT. OCT is important to
guide the appropriate balloon dilatation for good scaffold expansion to the vessel wall and minimize scaffold malapposition. It is not advisable to attempt BVS implantation without intracoronary imaging guidance. It is suggested that BVS can only be applied at the intended to treat diseased segment of CAE with a lumen diameter of not more than 4.0 mm as assessed by intracoronary imaging such as the OCT. This is in concordance with the limit of expansion of the largest available 3.5 mm diameter BVS. Therefore, in the strictest sense BVS can only be used for mild–moderate CAE with no excessive variance in lumen diameter and guided by intracoronary imaging. In conclusion, this case elegantly demonstrated the ingenious harnessing of the positive properties of the BVS to treat the coronary stenosis, reverse the abnormal negative remodeling process and heal the ectasia disease without leaving anything behind.
Fig. 2. Cardiac computed tomography angiography (CCTA) revealed an eccentric lesion or an ulcerated lesion (white arrow) in the RCA (A, C). Follow-up CCTA showed the radio-opaque marker (white arrow) of the BVS (white line) with noticeable luminal gain.
K.L. Yew / International Journal of Cardiology 190 (2015) 99–101
Conflict of interest The author reports no relationships that could be construed as a conflict of interest. References [1] R.H. Swanton, M.L. Thomas, D.J. Coltart, B.S. Jenkins, M.M. Webb-Peploe, B.T. Williams, Coronary artery ectasia variant of occlusive coronary arteriosclerosis, Br. Heart J. 40 (1978) 393–400. [2] P. Schoenhagen, K.M. Ziada, D.G. Vince, S.E. Nissen, E.M. Tuzcu, Arterial remodeling and coronary artery disease: the concept of “dilated” versus “obstructive” coronary atherosclerosis, J. Am. Coll. Cardiol. 38 (2001) 297–306. [3] M. Nakano, K. Yahagi, F. Otsuka, et al., Causes of early stent thrombosis in patients presenting with acute coronary syndrome: an ex vivo human autopsy study, J. Am. Coll. Cardiol. 63 (2014) 2510–2520. [4] G. Guagliumi, V. Sirbu, G. Musumeci, et al., Examination of the in vivo mechanisms of late drug-eluting stent thrombosis: findings from optical coherence tomography and intravascular ultrasound imaging, JACC Cardiovasc. Interv. 5 (2012) 12–20.
101
[5] F. D'Ascenzo, M. Bollati, F. Clementi, et al., Incidence and predictors of coronary stent thrombosis: evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses, Int. J. Cardiol. 167 (2013) 575–584. [6] R.J. van Geuns, C. Tamburino, J. Fajadet, et al., Self-expanding versus balloonexpandable stents in acute myocardial infarction: results from the APPOSITION II study, JACC Cardiovasc. Interv. 5 (2012) 1209–1219. [7] K.L. Yew, Novel use of absorb bioresorbable vascular scaffold and STENTYS selfapposing coronary stent for complex saphenous vein grafts intervention, Int. J. Cardiol. 177 (2014) e184–e185. [8] K.L. Yew, Early experience of transradial multivessel percutaneous coronary intervention with new generation STENTYS sirolimus eluting self-apposing stents for ectatic coronary arteries, Int. J. Cardiol. 185 (2015) 155–156. [9] S. Nakatani, Y. Ishibashi, P. Suwannasom, et al., Development and receding of a coronary artery aneurysm after implantation of a fully bioresorbable scaffold, Circulation 131 (2015) 764–767. [10] B. Cortese, P. Silva Orrego, R. Virmani, Late coronary BVS malapposition and aneurysm: a time for appraisal, Catheter. Cardiovasc. Interv. (2014)http://dx.doi.org/10. 1002/ccd.25766 (Epub ahead of print).
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Treating and healing coronary artery ectasia disease with Bioresorbable Vascular Scaffold Kuan Leong Yew Cardiology Department, Sarawak General Hospital Heart Center, Kota Samarahan, 94300 Sarawak, Malaysia
a r t i c l e
i n f o
Article history: Received 16 April 2015 Accepted 18 April 2015 Available online 21 April 2015 Keywords: Coronary artery ectasia Coronary artery aneurysm Bioresorbable vascular scaffold ABSORB Negative remodeling Fractional flow reserve
Coronary artery ectasia (CAE) disease is closely associated with atherosclerosis and coronary artery disease. In CAE, the affected coronary segment is enlarged and dilated to at least 1.5 times the diameter of the relatively normal adjacent coronary [1,2]. There is abnormality of coronary artery remodeling in CAE with atherosclerotic disease [2]. Therefore, it is worthwhile to report a case treated with bioresorbable vascular scaffold (BVS) (Abbott Vascular, Santa Clara, USA) which was shown to heal the coronary stenosis and reversed the abnormal coronary artery remodeling process in CAE. A 56-year-old man with dyslipidemia had 1 year history of atypical chest pain. The exercise treadmill test was inconclusive and the cardiac computed tomography angiography (CCTA) showed ectasia disease of the coronaries and an eccentric tight lesion prior to the beginning of an ectatic segment in the right coronary artery (RCA) (Fig. 2A, C). Thus, he underwent an elective transradial coronary angiography study. It showed large ectatic segments at the prox–mid-RCA and distal RCA with a preceding eccentric lesion (Fig. 1A, B, C), ectatic prox–midleft anterior descending artery followed by small caliber of the remaining LAD and mild ectasia of the left circumflex artery. The optical coherence tomography (OCT) confirmed the eccentric narrowing prior to the beginning of a big ectatic distal segment of the RCA (Fig. 1E). Fractional flow reserve (FFR) demonstrated a value of 0.76 at maximal hyperemia. We proceeded to perform transradial percutaneous coronary intervention (PCI). The lesion was predilated with E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2015.04.150 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
a 3.0 × 15 mm semi-compliant balloon. A 3.5 × 28 mm BVS was positioned at the mid–distal RCA with the distal part of the BVS covering the eccentric lesion site and slightly encroaching into the proximal segment of the distal coronary ectasia (Fig. 1D). The BVS was postdilated with a 4.0 × 8 mm non-compliant balloon. Postdilatation OCT showed adequate coverage of the eccentric lesion site with no geographical miss and generally well apposed scaffolds (Fig. 1F). The patient remained well and the 18 month follow-up CCTA showed the disappearance of the eccentric lesion and mild late lumen gain of the treated RCA segment (Fig. 2B, D). PCI in a coronary artery affected by an ectatic or aneurysmal segment is technically challenging in view of the luminal diameter discrepancy, tapering shape and vessel wall contour irregularity. The application of conventional balloon-expandable metallic stents seemed to be an ill-fitting solution for these atypical coronary anatomies. Overzealous stent expansion in order to chase the eventual size of the ectatic segment may result in coronary dissection, hematoma or perforation. Underexpansion of the tubular metallic stent would lead to the higher risk of stent strut malapposition and stent thrombosis [3–6]. With the advent and availability of self-apposing stents such the STENTYS (STENTYS SA, Paris, France) stent, it gave much hope and reassurance in dealing with the unmet needs in the treatment of CAE. In the real world setting, self-apposing STENTYS stents have been used successfully for the treatment of variable coronary ectasia and aneurysmal disease, saphenous vein graft and acute coronary syndrome [6–8]. The initial technical success and short term result seemed favorable thus far. STENTYS is made from nitinol and nickel–titanium alloy with selfexpanding property. However, this is also a type of metallic stent which is permanently implanted in the coronary artery. Hence, it would be beneficial if we can implant a stent with drug eluting property to treat the initial coronary disease in CAE and “disappear” after the completion of the job without the worry of long term risk of stent malapposition and stent thrombosis. Everolimus-eluting BVS can prevent coronary restenosis and restore coronary vasomotion with late luminal enlargement and eventual freedom from permanent metallic caging of the coronaries. BVS is completely resorbed after 2–3 years and the risk of scaffold thrombosis is gone too. The BVS was carefully positioned under fluoroscopic guidance to ensure minimal scaffold protrusion into the post-stenotic ectatic segment and avoid geographical miss of the eccentric lesion. Too much scaffolding of the ectatic segment would increase the probability of scaffold malapposition and acute thrombosis risk. Lately, there have been
100
K.L. Yew / International Journal of Cardiology 190 (2015) 99–101
Fig. 1. Coronary angiography showing the eccentricity of the lesion (black arrow) which was complicated by a large post-stenotic ectatic distal right coronary artery (RCA) segment (A–C). A 3.5 × 28 mm BVS was deployed from the mid-RCA to distal ectatic segment (D). Optical coherence tomography (OCT) demonstrated the significant narrowing (black arrow) and ectatic nature of the RCA (E). OCT showed that the BVS was well expanded and well apposed to the vessel wall (F).
some signals about BVS associated scaffold malapposition and coronary aneurysm [9,10]. Scaffolding of the ectatic segment could have inadvertently accentuated the positive remodeling process, further luminal enlargement and worsened the luminal discrepancy. The relatively small caliber mid–distal RCA segment could have been afflicted by the negative remodeling pathology of CAE. The BVS was shown to reverse this process and increased the lumen size as evidenced by the 18 month follow-up CCTA. Thus, BVS should be avoided or minimized in a big ectatic segment to prevent excessive positive remodeling and luminal enlargement, and may be applied in a narrow tubular segment to reverse the inherent negative remodeling process. The key towards the successful application of BVS in this atypical coronary anatomy was the adequate lesion preparation with balloon predilatation and intracoronary imaging with OCT. OCT is important to
guide the appropriate balloon dilatation for good scaffold expansion to the vessel wall and minimize scaffold malapposition. It is not advisable to attempt BVS implantation without intracoronary imaging guidance. It is suggested that BVS can only be applied at the intended to treat diseased segment of CAE with a lumen diameter of not more than 4.0 mm as assessed by intracoronary imaging such as the OCT. This is in concordance with the limit of expansion of the largest available 3.5 mm diameter BVS. Therefore, in the strictest sense BVS can only be used for mild–moderate CAE with no excessive variance in lumen diameter and guided by intracoronary imaging. In conclusion, this case elegantly demonstrated the ingenious harnessing of the positive properties of the BVS to treat the coronary stenosis, reverse the abnormal negative remodeling process and heal the ectasia disease without leaving anything behind.
Fig. 2. Cardiac computed tomography angiography (CCTA) revealed an eccentric lesion or an ulcerated lesion (white arrow) in the RCA (A, C). Follow-up CCTA showed the radio-opaque marker (white arrow) of the BVS (white line) with noticeable luminal gain.
K.L. Yew / International Journal of Cardiology 190 (2015) 99–101
Conflict of interest The author reports no relationships that could be construed as a conflict of interest. References [1] R.H. Swanton, M.L. Thomas, D.J. Coltart, B.S. Jenkins, M.M. Webb-Peploe, B.T. Williams, Coronary artery ectasia variant of occlusive coronary arteriosclerosis, Br. Heart J. 40 (1978) 393–400. [2] P. Schoenhagen, K.M. Ziada, D.G. Vince, S.E. Nissen, E.M. Tuzcu, Arterial remodeling and coronary artery disease: the concept of “dilated” versus “obstructive” coronary atherosclerosis, J. Am. Coll. Cardiol. 38 (2001) 297–306. [3] M. Nakano, K. Yahagi, F. Otsuka, et al., Causes of early stent thrombosis in patients presenting with acute coronary syndrome: an ex vivo human autopsy study, J. Am. Coll. Cardiol. 63 (2014) 2510–2520. [4] G. Guagliumi, V. Sirbu, G. Musumeci, et al., Examination of the in vivo mechanisms of late drug-eluting stent thrombosis: findings from optical coherence tomography and intravascular ultrasound imaging, JACC Cardiovasc. Interv. 5 (2012) 12–20.
101
[5] F. D'Ascenzo, M. Bollati, F. Clementi, et al., Incidence and predictors of coronary stent thrombosis: evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses, Int. J. Cardiol. 167 (2013) 575–584. [6] R.J. van Geuns, C. Tamburino, J. Fajadet, et al., Self-expanding versus balloonexpandable stents in acute myocardial infarction: results from the APPOSITION II study, JACC Cardiovasc. Interv. 5 (2012) 1209–1219. [7] K.L. Yew, Novel use of absorb bioresorbable vascular scaffold and STENTYS selfapposing coronary stent for complex saphenous vein grafts intervention, Int. J. Cardiol. 177 (2014) e184–e185. [8] K.L. Yew, Early experience of transradial multivessel percutaneous coronary intervention with new generation STENTYS sirolimus eluting self-apposing stents for ectatic coronary arteries, Int. J. Cardiol. 185 (2015) 155–156. [9] S. Nakatani, Y. Ishibashi, P. Suwannasom, et al., Development and receding of a coronary artery aneurysm after implantation of a fully bioresorbable scaffold, Circulation 131 (2015) 764–767. [10] B. Cortese, P. Silva Orrego, R. Virmani, Late coronary BVS malapposition and aneurysm: a time for appraisal, Catheter. Cardiovasc. Interv. (2014)http://dx.doi.org/10. 1002/ccd.25766 (Epub ahead of print).
