Excimer Laser Coronary Angioplasty and Drug-Coated Balloon Treatment for Very Late Stent Thrombosis Due to Neoatherosclerosis as Assessed by Optical Coherence Tomography

An 80-year-old man with a bare-metal stent (BMS) that had been implanted in the right coronary artery (RCA) 20 years ago was admitted to hospital because of non-ST-segment elevation myocardial infarction. Coronary angiography revealed 99% in-stent restenosis (ISR) in the mid-RCA (Figure A). Optical coherence tomography (OCT) revealed neoatherosclerosis and plaque rupture, together with thrombus at the ISR site. We performed percutaneous coronary intervention with a 1.4-mm catheter for excimer laser coronary angioplasty (ELCA) at energy settings of up to 60 mJ/mm² and 40 Hz to prevent slow flow because of lipidic plaques and thrombus firstly. On post-ELCA OCT, minimum lumen area improved from 0.9 to 3.4 mm² and there was transpiration of the thrombus (Figure B). Finally, a 4.0-mm drug-coated balloon (DCB) was used and TIMI 3 flow was obtained (Figure C). The patient was discharged after an uneventful clinical course.

Figure.

CAG (A–C) and OCT (A1–C1) images pre-PCI, post-ELCA, and final, respectively. Pre-PCI OCT images demonstrate thrombus in the cavity of the ruptured plaque with thin-capped lipid-laden plaque. On the post-ELCA and final imaging, the MLA had enlarged significantly. The white arrows indicate the MLA corresponding to the OCT image. The white arrowheads indicate the thrombus in the cavity of the ruptured plaque. CAG, coronary angiography; ELCA, excimer laser coronary angioplasty; MLA, minimum lumen area; OCT, optical coherence tomography; PCI, percutaneous coronary intervention.

According to previous studies, ELCA can prevent post-PCI coronary flow deterioration in acute coronary syndrome culprit lesion.¹ However, there are few reports on the efficacy of ELCA for ISR with neoatherosclerosis. To the our best knowledge, this is the first report of a case of very late stent thrombosis due to neoatherosclerosis and plaque rupture in a BMS, as assessed by OCT and successfully treated with ELCA and DCB.

Disclosures

Nothing to disclose.

Reference

• 1.   Kujiraoka H, Tsuchiyama T, Inagaki D, Yoshida K, Fukamizu S. Comparison of the efficacy of excimer laser coronary angioplasty for ST-segment elevation myocardial infarction with onset-to-balloon time. Lasers Med Sci 2023; 38: 126.