Overwhelming Suppression of Neointimal Coverage on High-Resolution Coronary Angioscopy After Paclitaxel-Coated Balloon Angioplasty for In-Stent Restenosis of Cobalt-Chrome Everolimus-Eluting Stent

A 60-year-old man with stable angina pectoris was implanted with a 3.0×38-mm cobalt-chrome everolimus-eluting stent (CoCr-EES) in the proximal left anterior descending coronary artery. He also had atherosclerotic risk factors, including refractory hypertension and uncontrollable diabetes mellitus. Four antihypertensive drugs were prescribed, and hemoglobin A1c increased up to 8.0% under medication and insulin. Nine months later, angina worsened and coronary angiography (CAG) showed in-stent restenosis (Figure A). Subsequently, paclitaxel-coated balloon (PCB) angioplasty was satisfactory on angiography. At 12-month follow-up, there was no significant stenotic lesions on scheduled CAG (Figure B). Coronary angioscopy (CAS; Forwardlooking^®, OVALIS, Osaka, Japan) showed a significant suppression of neointimal growth, several thrombi, naked stent struts, and brilliant yellow plaque underneath the CoCr-EES (Figure C–F; Movie S1). Paclitaxel suppresses the neointimal growth differently compared with the agents belonging to the limus family. Awata et al reported different distributions of dominant neointimal coverage grades following the implantation of paclitaxel-eluting stents (PES) and sirolimus-eluting stents.¹ Remarkably, chronic PCB on CAS seemed to be similar to that of chronic PES. As a result, we were reluctant to stop the dual anti-platelet therapy (DAPT). Based on CAS, careful follow-up after PCB angioplasty should be considered, including decisions regarding the optimal time to discontinue DAPT.

Figure.

(A) Coronary angiography (CAG) showing the presence of severe diffuse stenosis at the cobalt-chrome everolimus-eluting stent (CoCr-EES) site in the proximal left ascending coronary artery. (B) Using a 3.0×30-mm paclitaxel-coated balloon (PCB), 12-month follow-up CAG showed no significant stenotic lesions. (C) PCB was untouched at this site. Although stent struts were observed, some struts were embedded with white neointimal coverage. (D–F) PCB was in contact with the in-stent restenosis sites at these locations; stent struts were completely visible, similar to those immediately after implantation; some red, peri-stent thrombi congregation on struts and brilliant yellow plaque underneath the CoCr-EES were observed, suggestive of an inflammatory reaction on the vessel wall. CAS, coronary angioscopy.

Disclosures

The authors declare no conflict of interest.

Supplementary Files

Supplementary File 1

Movie S1. Coronary angioscopy showed overwhelming suppression of neointimal growth, multiple peri- and in-stent thrombi, glittering naked stent struts, and brilliant yellow plaque underneath the cobalt-chrome everolimus-eluting stent.

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-18-0160

Reference

• 1.   Awata M, Nanto S, Uematsu M, Morozumi T, Watanabe T, Onishi T, et al. Heterogeneous arterial healing in patients following paclitaxel-eluting stent implantation: Comparison with sirolimus-eluting stents. JACC Cardiovasc Interv 2009; 2: 453–458.