International Journal of Cardiology 185 (2015) 150–152
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Transradial percutaneous coronary intervention with Stentys self-apposing stents and Stentys–Yew technique for angulated and ectatic coronary artery Kuan Leong Yew ⁎, Zarrin Kang 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 31 January 2015 Accepted 7 March 2015 Available online 10 March 2015 Keywords: Stentys Tortuous Self-apposing stent Coronary ectasia Transradial
A 72-year-old man had chest pain for 1 week before seeking treatment and was diagnosed to have late presentation ST segment elevation myocardial infarction at an initial institution. There were Q waves and T wave inversion in leads V1–V3. He was treated medically and underwent a treadmill stress test prior to discharge. The test was terminated at Stage 1 with the development of ST segment depression over anterolateral and inferior leads and mild chest pain. Thus, he was transferred to our medical institution. Cardiac enzymes were mildly elevated and echocardiogram showed anteroseptal hypokinesia with systolic ejection fraction of 45%. Coronary angiography revealed 2 vessel disease with distal left main (LM) involvement. The coronaries were generally large and ectatic. There were critical stenoses at proximal–mid right coronary artery (RCA) junction and mid RCA (Fig.1A), 80% stenosis at proximal left anterior descending artery (LAD) and mild–moderate distal LM disease. His case was discussed at our heart team meeting and surgery was suggested as the preferred mode of revascularization. However, he declined surgery and requested percutaneous coronary intervention (PCI). Although he had Alzheimer's disease, he was physically active with satisfactory functional capacity. The elective PCI procedure was done transradially. A cocktail of diazepam and fentanyl was given at the start of the procedure when the patient exhibited restlessness demeanor. A 6F JR 4 guiding catheter (GC) was used to engage the RCA and the RCA lesions were predilated ⁎ Corresponding author. E-mail address: [email protected] (K.L. Yew).
http://dx.doi.org/10.1016/j.ijcard.2015.03.127 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
with a 2.75 × 15 mm semi-compliant balloon (Fig.1B). A second Sion (Asahi Intecc Co, Aichi, Japan) coronary wire was used as a buddy wire to enable a 3.0–3.5 × 22 mm Stentys (STENTYS SA, Paris, France) selfapposing drug eluting coronary stent to be positioned at mid–distal RCA and deployed successfully (Fig.1C). We had resistance in delivering a 3.5–4.0 × 27 mm Stentys into the GC with 2 coronary wires in-situ. When the second coronary wire was removed, the whole GC support was compromised. Despite downsizing to 3.0–3.5 × 22 mm Stentys with buddy wire support and further balloon predilatations (Fig.1D–E), we still failed to deliver this Stentys. The 3.0–3.5 mm Stentys was manually reshaped with a gentle curve (Fig.1F). The reshaped Stentys could successfully cross the acute proximal RCA angulation but its length was not enough to overlap with the mid RCA Stentys (Fig. 2A). There was some haziness at the unstented segment (Fig. 2B). After the Stentys stents were postdilated with a 4.0 × 15 mm non-compliant balloon (Fig. 2C), the haziness at mid segment became more obvious with new development of inferior ST segment elevation and chest pain. A shorter and slightly curved 3.0–3.5 × 17 mm Stentys was quickly positioned and deployed at the mid RCA (Fig. 2D). The whole stented segment was postdilated with 5.0 × 12 mm non-compliant balloon with good angiographic result (Fig. 2F) and resolution of the chest pain and ST segment. The patient was getting more restless and he was rescheduled for stage PCI to the left coronary system. His Syntax score was 25, placing him in the intermediate tercile with coronary artery bypass grafting shown to have lower major adverse cardiac and cerebrovascular events, death, MI, and repeat revascularization compared to PCI [1]. Nevertheless, PCI was a feasible option but technically challenging in view of the coronary ectasia and large coronary diameter and size discrepancy. Conventional metallic stents and resorbable scaffolds are not suitable for treating such atypical coronary arteries. Self-apposing stents are available in large sizes for large diameter coronary artery and conform well to vessel lumen. The Stentys self-expanding stent system is a bulky device which has been used successfully for coronary ectasia, saphenous vein graft, acute myocardial infarction, bifurcation, LM, large vessel lumen and tapered vessel [2–4]. The stent and covering sheath must be delivered to the targeted lesion site with resultant reduced deliverability and trackability vis a vis contemporary balloon-expanded stents. The patient's RCA was complex and extremely angulated at the first curvature (Fig. 1A). In fact, the predilatations, buddy wire technique and choice of moderate size and length of the stent ensured its initial
K.L. Yew, Z. Kang / International Journal of Cardiology 185 (2015) 150–152
151
Fig. 1. Coronary angiography of the right coronary artery (RCA) showing the extreme angulation and coronary stenoses (A). Adequate lesion preparation with balloon predilatation is recommended (B). The deployment of the first 3.0–3.5 × 22 mm Stentys at mid–distal RCA with buddy wire support (C). Repeated balloon predilatation to facilitate subsequent stent delivery (D, E). Manually reshaping the Stentys to overcome and navigate the extreme angulation at the prox–mid RCA (F).
successful deployment at mid–distal RCA. The operator found that the conventional 6F GC with an inner lumen diameter of about 0.070 in. could not accommodate large size 3.5–4.0 mm Stentys with other concomitant 2 coronary wires. On the other hand, the medium size 3.0– 3.5 × 22 mm Stentys encountered tip catch phenomenon at the first RCA curvature. The large and medium size Stentys could not pass into a 6F GuideLiner (Vascular Solutions Inc., Minneapolis, Minnesota, United States) during ex-vivo trial of guide extension catheter. After encountering all these problematic scenarios, the operator decided to improvise and gently bent the tip and covering sheath. Fortuitously, it could navigate the extreme proximal RCA angulation with constant and consistent forward pressure and aided by buddy wiring support for spot stenting of the first lesion. Perhaps, the repeated attempts of balloon dilatation, stent passage and postdilatation inadvertently caused the angiographically significant coronary dissection which was treated and sealed by a 3.0–3.5 × 17 mm Stentys (Fig. 2D).
There were several learning points in this case. A bigger and more aggressive GC such as Amplatz GC would provide better support and allow more generous allowance for the passage of bigger size Stentys, guide extension catheter and multiple coronary wires for buddy wiring purpose. Only a larger diameter guide extension catheter may accommodate the Stentys if facilitation of stent delivery is anticipated. Thus, the transfemoral approach with the larger diameter GC should be planned from the outset for wider backup choices. However, transradial PCI was a preferred choice for this elderly patient with Alzheimer's disease, mainly to reduce and minimize vascular access related complication. The simple but useful maneuver of reshaping the Stentys could greatly improve the stent deliverability in coronaries with tortuous and angulated segments. Finally, transradial PCI for challenging coronary anatomy with Stentys is still feasible with this new technology offering a sanguine future for the unmet needs of atypical coronaries.
Fig. 2. A 3.0–3.5 × 22 mm Stentys was positioned at prox–mid RCA with buddy wire support despite guiding catheter kickback (A). Stent edge haziness (black arrow) post-deployment of 2 Stentys (white lines) (B). Postdilatations of the stents accentuated the dissection at the intervening unstented segment (C). A 3.0–3.5 × 17 mm Stentys was quickly deployed to treat the dissection (D). Immediate coronary angiography post-deployment of the short Stentys (E). After further postdilatation with a 5.0 × 12 mm non-compliant balloon, there was excellent final angiographic result (F).
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K.L. Yew, Z. Kang / International Journal of Cardiology 185 (2015) 150–152
Conflict of interest The author reports no relationships that could be construed as a conflict of interest. References [1] S.J. Head, P.M. Davierwala, P.W. Serruys, et al., Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final
five-year follow-up of the SYNTAX trial, Eur. Heart J. 35 (40) (Oct 21 2014) 2821–2830. [2] C. Moretti, P. Omedè, D.G. Presutti, et al., Shaping an ectatic coronary artery: Stentys implantation, Int. J. Cardiol. 171 (2014) 459–461. [3] R.J. van Geuns, K. Awad, A. IJsselmuiden, K. Koch, The role of self-expanding stents in patients with atypical coronary anatomy, Interv. Cardiol. Rev. 9 (2014) 11–16. [4] K.L. Yew, Novel use of absorb bioresorbable vascular scaffold and STENTYS self-apposing coronary stent for complex saphenous vein grafts intervention, Int. J. Cardiol. 177 (2014) e184–e185.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Transradial percutaneous coronary intervention with Stentys self-apposing stents and Stentys–Yew technique for angulated and ectatic coronary artery Kuan Leong Yew ⁎, Zarrin Kang 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 31 January 2015 Accepted 7 March 2015 Available online 10 March 2015 Keywords: Stentys Tortuous Self-apposing stent Coronary ectasia Transradial
A 72-year-old man had chest pain for 1 week before seeking treatment and was diagnosed to have late presentation ST segment elevation myocardial infarction at an initial institution. There were Q waves and T wave inversion in leads V1–V3. He was treated medically and underwent a treadmill stress test prior to discharge. The test was terminated at Stage 1 with the development of ST segment depression over anterolateral and inferior leads and mild chest pain. Thus, he was transferred to our medical institution. Cardiac enzymes were mildly elevated and echocardiogram showed anteroseptal hypokinesia with systolic ejection fraction of 45%. Coronary angiography revealed 2 vessel disease with distal left main (LM) involvement. The coronaries were generally large and ectatic. There were critical stenoses at proximal–mid right coronary artery (RCA) junction and mid RCA (Fig.1A), 80% stenosis at proximal left anterior descending artery (LAD) and mild–moderate distal LM disease. His case was discussed at our heart team meeting and surgery was suggested as the preferred mode of revascularization. However, he declined surgery and requested percutaneous coronary intervention (PCI). Although he had Alzheimer's disease, he was physically active with satisfactory functional capacity. The elective PCI procedure was done transradially. A cocktail of diazepam and fentanyl was given at the start of the procedure when the patient exhibited restlessness demeanor. A 6F JR 4 guiding catheter (GC) was used to engage the RCA and the RCA lesions were predilated ⁎ Corresponding author. E-mail address: [email protected] (K.L. Yew).
http://dx.doi.org/10.1016/j.ijcard.2015.03.127 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
with a 2.75 × 15 mm semi-compliant balloon (Fig.1B). A second Sion (Asahi Intecc Co, Aichi, Japan) coronary wire was used as a buddy wire to enable a 3.0–3.5 × 22 mm Stentys (STENTYS SA, Paris, France) selfapposing drug eluting coronary stent to be positioned at mid–distal RCA and deployed successfully (Fig.1C). We had resistance in delivering a 3.5–4.0 × 27 mm Stentys into the GC with 2 coronary wires in-situ. When the second coronary wire was removed, the whole GC support was compromised. Despite downsizing to 3.0–3.5 × 22 mm Stentys with buddy wire support and further balloon predilatations (Fig.1D–E), we still failed to deliver this Stentys. The 3.0–3.5 mm Stentys was manually reshaped with a gentle curve (Fig.1F). The reshaped Stentys could successfully cross the acute proximal RCA angulation but its length was not enough to overlap with the mid RCA Stentys (Fig. 2A). There was some haziness at the unstented segment (Fig. 2B). After the Stentys stents were postdilated with a 4.0 × 15 mm non-compliant balloon (Fig. 2C), the haziness at mid segment became more obvious with new development of inferior ST segment elevation and chest pain. A shorter and slightly curved 3.0–3.5 × 17 mm Stentys was quickly positioned and deployed at the mid RCA (Fig. 2D). The whole stented segment was postdilated with 5.0 × 12 mm non-compliant balloon with good angiographic result (Fig. 2F) and resolution of the chest pain and ST segment. The patient was getting more restless and he was rescheduled for stage PCI to the left coronary system. His Syntax score was 25, placing him in the intermediate tercile with coronary artery bypass grafting shown to have lower major adverse cardiac and cerebrovascular events, death, MI, and repeat revascularization compared to PCI [1]. Nevertheless, PCI was a feasible option but technically challenging in view of the coronary ectasia and large coronary diameter and size discrepancy. Conventional metallic stents and resorbable scaffolds are not suitable for treating such atypical coronary arteries. Self-apposing stents are available in large sizes for large diameter coronary artery and conform well to vessel lumen. The Stentys self-expanding stent system is a bulky device which has been used successfully for coronary ectasia, saphenous vein graft, acute myocardial infarction, bifurcation, LM, large vessel lumen and tapered vessel [2–4]. The stent and covering sheath must be delivered to the targeted lesion site with resultant reduced deliverability and trackability vis a vis contemporary balloon-expanded stents. The patient's RCA was complex and extremely angulated at the first curvature (Fig. 1A). In fact, the predilatations, buddy wire technique and choice of moderate size and length of the stent ensured its initial
K.L. Yew, Z. Kang / International Journal of Cardiology 185 (2015) 150–152
151
Fig. 1. Coronary angiography of the right coronary artery (RCA) showing the extreme angulation and coronary stenoses (A). Adequate lesion preparation with balloon predilatation is recommended (B). The deployment of the first 3.0–3.5 × 22 mm Stentys at mid–distal RCA with buddy wire support (C). Repeated balloon predilatation to facilitate subsequent stent delivery (D, E). Manually reshaping the Stentys to overcome and navigate the extreme angulation at the prox–mid RCA (F).
successful deployment at mid–distal RCA. The operator found that the conventional 6F GC with an inner lumen diameter of about 0.070 in. could not accommodate large size 3.5–4.0 mm Stentys with other concomitant 2 coronary wires. On the other hand, the medium size 3.0– 3.5 × 22 mm Stentys encountered tip catch phenomenon at the first RCA curvature. The large and medium size Stentys could not pass into a 6F GuideLiner (Vascular Solutions Inc., Minneapolis, Minnesota, United States) during ex-vivo trial of guide extension catheter. After encountering all these problematic scenarios, the operator decided to improvise and gently bent the tip and covering sheath. Fortuitously, it could navigate the extreme proximal RCA angulation with constant and consistent forward pressure and aided by buddy wiring support for spot stenting of the first lesion. Perhaps, the repeated attempts of balloon dilatation, stent passage and postdilatation inadvertently caused the angiographically significant coronary dissection which was treated and sealed by a 3.0–3.5 × 17 mm Stentys (Fig. 2D).
There were several learning points in this case. A bigger and more aggressive GC such as Amplatz GC would provide better support and allow more generous allowance for the passage of bigger size Stentys, guide extension catheter and multiple coronary wires for buddy wiring purpose. Only a larger diameter guide extension catheter may accommodate the Stentys if facilitation of stent delivery is anticipated. Thus, the transfemoral approach with the larger diameter GC should be planned from the outset for wider backup choices. However, transradial PCI was a preferred choice for this elderly patient with Alzheimer's disease, mainly to reduce and minimize vascular access related complication. The simple but useful maneuver of reshaping the Stentys could greatly improve the stent deliverability in coronaries with tortuous and angulated segments. Finally, transradial PCI for challenging coronary anatomy with Stentys is still feasible with this new technology offering a sanguine future for the unmet needs of atypical coronaries.
Fig. 2. A 3.0–3.5 × 22 mm Stentys was positioned at prox–mid RCA with buddy wire support despite guiding catheter kickback (A). Stent edge haziness (black arrow) post-deployment of 2 Stentys (white lines) (B). Postdilatations of the stents accentuated the dissection at the intervening unstented segment (C). A 3.0–3.5 × 17 mm Stentys was quickly deployed to treat the dissection (D). Immediate coronary angiography post-deployment of the short Stentys (E). After further postdilatation with a 5.0 × 12 mm non-compliant balloon, there was excellent final angiographic result (F).
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K.L. Yew, Z. Kang / International Journal of Cardiology 185 (2015) 150–152
Conflict of interest The author reports no relationships that could be construed as a conflict of interest. References [1] S.J. Head, P.M. Davierwala, P.W. Serruys, et al., Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final
five-year follow-up of the SYNTAX trial, Eur. Heart J. 35 (40) (Oct 21 2014) 2821–2830. [2] C. Moretti, P. Omedè, D.G. Presutti, et al., Shaping an ectatic coronary artery: Stentys implantation, Int. J. Cardiol. 171 (2014) 459–461. [3] R.J. van Geuns, K. Awad, A. IJsselmuiden, K. Koch, The role of self-expanding stents in patients with atypical coronary anatomy, Interv. Cardiol. Rev. 9 (2014) 11–16. [4] K.L. Yew, Novel use of absorb bioresorbable vascular scaffold and STENTYS self-apposing coronary stent for complex saphenous vein grafts intervention, Int. J. Cardiol. 177 (2014) e184–e185.
