Coronary angioscopy and optical coherence

IJCA-18543; No of Pages 3
International Journal of Cardiology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Cardiology
journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Coronary angioscopy and optical coherence tomography
for conﬁrmation of drug-coated neointimal plaque after paclitaxelcoated balloon angioplasty for in-stent restenosis
Kihei Yoneyama, Kohei Koyama, Yasuhiro Tanabe, Takanobu Mitarai, Ryo Kamijima, Shingo Kuwata,
Hiroshi Yamazaki, Emi Nakano, Ken Kongoji, Tomoo Harada, Yoshihiro J. Akashi ⁎
Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
a r t i c l e
i n f o
Article history:
Received 7 July 2014
Accepted 27 July 2014
Available online xxxx
Keywords:
Angioplasty
Bare-metal stent
Drug-coated balloon
Drug-eluting balloon
Neointima
The paclitaxel drug-coated balloon (DCB) is an emerging device in
percutaneous coronary intervention (PCI); it allows a rapid local release
of an antirestenotic drug without the use of a durable polymer or metal
scaffold [1]. The DCB has been proven to be effective with paclitaxel in
preclinical trials and in clinical practice for the treatment of coronary
lesions such as in-stent restenosis (ISR), de novo and bifurcation lesions,
and those involving the peripheral arteries [2–4]. However, only a few
reports on imaging of the drug covering the neointimal plaque at the
ISR have been published. Here, we report conﬁrmation of drug-coated
neointimal plaque at the ISR lesion after paclitaxel DCB angioplasty
with coronary angioscopy and optical coherence tomography (OCT).
A 70-year-old man underwent a bare metal stent (Multi-link 8,
3.5 × 28 mm, Abbott Vascular, Santa Clara, CA, USA) implantation
in the proximal left anterior descending artery (LAD) for acute myocardial
infarction. Six-month follow-up coronary angiography demonstrated a
critical ISR of the proximal LAD. The ISR was dilated using a conventional
balloon (NC TENKU 3.25 × 15 mm, St Jude Medical Co, St. Paul, Minnesota,
USA) with satisfactory ﬁnal angiographic results (Fig. 1). OCT (C7XR
system St Jude Medical Co, St. Paul, Minnesota, USA) revealed a severe
neointimal plaque over the bare-metal stent (Fig. 2 and Movie 1). The
⁎ Corresponding author at: Division of Cardiology, Department of Internal Medicine,
St. Marianna University School of Medicine, 2-16-1, Sugao, Miyamae-ku, Kawasaki-City,
Kanagawa 216–8511, Japan. Tel.: +81 44 977 8111; fax: +81 44 976 7093.
E-mail address: [email protected] (Y.J. Akashi).
angioscope (Vecmova NEO, FiberTech, Tokyo, Japan) was manually
pulled back from the distal to the proximal end with ﬂuid infusion, and
invisible stent struts with full neointimal coverage with white plaque
mixed with minor hemorrhage after the conventional ballooning was
conﬁrmed. Subsequently, a DCB (Sequent Please 3.0 × 26 mm, B. Braun
Melsungen, Berlin, Germany) was dilated at nominal pressure for 50 s
at the ISR lesion. OCT demonstrated a successful drug covering of the
neointimal plaque by the DCB (Fig. 2 and Movie 2). Additionally,
angioscopy conﬁrmed the drug-coated neointimal plaque at the ISR
lesion (Fig. 3 and Movie 3). The patient was discharged on dual antiplatelet therapy (DAPT).
DCB is highly effective in patients presenting with ISR. Its clinical
application involves local drug delivery to the target vessel wall because
otherwise the drug would be released into the blood before reaching the
target lesion. Our ﬁndings support the DCB technique's usefulness in
drug delivery on the neointimal plaque in human coronary lesions. To
our knowledge, this is the ﬁrst report of conﬁrmation of drug-coated
neointimal plaque at the ISR lesion by the paclitaxel-coated balloon
using coronary angioscopy. Another concern would be whether the
drug would get attached closely on the target vessel wall if it is a nonsmooth neointimal surface after conventional balloon angioplasty. In
the present case, OCT revealed uncovered lesions due to a disruption
of the neointimal surface after conventional balloon angioplasty. We
do not know if the incomplete coverage detected by OCT imaging can
be associated with further restenosis after DCB. Thus, additional imaging studies in patients with ISR are required to conﬁrm the possibility
of further developing a recurrent neointimal plaque at the incomplete
covered segment after DCB. Despite no established protocol currently
available for DAPT after DCB, we recommend treatment with DAPT
after DCB to reduce cardiovascular events associated with acute and/
or late stent thrombosis secondary to the foreign substances detected
on the surface of the target lesion by angioscopy and OCT imaging.
These coronary imaging modalities can resolve this issue by identifying
the optimal duration of DAPT after DCB with respect to pathology.
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.ijcard.2014.07.224.
Sources of funding
None.
http://dx.doi.org/10.1016/j.ijcard.2014.07.224
0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Yoneyama K, et al, Coronary angioscopy and optical coherence tomography for conﬁrmation of drug-coated neointimal
plaque after paclitaxel-coated balloon angioplasty for in-stent restenosis, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.07.224
2
K. Yoneyama et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Treatment of coronary in-stent restenosis with a paclitaxel-coated balloon. (A) Coronary angiography showing in-stent (bare-metal stent) restenosis at the proximal left anterior
descending artery. (B) Drug-coating balloon after balloon angioplasty. (C) Final angiography.
Fig. 2. Optical coherence tomography images of coronary in-stent restenosis with a paclitaxel-coated balloon. (A1) After balloon angioplasty, OCT revealed a severe neointimal plaque
within the bare-metal stent. (A2) Neointimal coverage with a large view. (B1) Successful covered neointimal plaque by a paclitaxel-coated balloon. (B2) There are thin high signals
(white arrow) around the smooth surface. The shadows (*) are from the surface of the neointimal plaque. (B3) Spotty high signal (white arrow) with shadow indicating the granular
drug covered area. (B4) Uncovered lesion at segmental level due to the disruption of the neointimal surface after balloon angioplasty.
Conﬂict of interest
None.
References
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[3] Unverdorben M, Vallbracht C, Cremers B, et al. Paclitaxel-coated balloon catheter
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Circulation 2009;119:2986–94.
[4] Scheller B, Hehrlein C, Bocksch W, et al. Treatment of coronary in-stent restenosis
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[1] Loh JP, Waksman R. Paclitaxel drug-coated balloons: a review of current status and
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Please cite this article as: Yoneyama K, et al, Coronary angioscopy and optical coherence tomography for conﬁrmation of drug-coated neointimal
plaque after paclitaxel-coated balloon angioplasty for in-stent restenosis, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.07.224
K. Yoneyama et al. / International Journal of Cardiology xxx (2014) xxx–xxx
3
Fig. 3. Angioscopy of coronary in-stent restenosis with a paclitaxel-coated balloon. (A) Invisible stent struts with full neointimal coverage with white plaque. (B) Appearance of
hemorrhage in neointimal plaque after plain old balloon angioplasty (POBA). (C) Conﬁrmation of the successful coverage of paclitaxel over the neointimal plaque. There were visible
white granular materials on the covered neointimal plaque.
Please cite this article as: Yoneyama K, et al, Coronary angioscopy and optical coherence tomography for conﬁrmation of drug-coated neointimal
plaque after paclitaxel-coated balloon angioplasty for in-stent restenosis, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.07.224

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