Novel use of absorb bioresorbable vascular scaffold and STENTYS

IJCA-18663; No of Pages 2
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
Novel use of absorb bioresorbable vascular scaffold and STENTYS
self-apposing coronary stent for complex saphenous vein
grafts intervention
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 6 August 2014
Accepted 9 August 2014
Available online xxxx
Keywords:
Saphenous vein graft intervention
Ectatic
Aneurysm
Bioresorbable vascular scaffold
Stentys
Self-apposing stent
A 53-year-old man suffered an episode of severe chest pain while he
was working at an overseas project. After the chest pain had subsided,
he ﬂew back to his home country and was admitted to our hospital.
The electrocardiography and cardiac enzymes were normal. His cardiovascular risk factors were type II diabetes mellitus, hypercholesterolemia and hypertension. He had coronary artery bypass grafting
(CABG) surgery in 2001 with left internal mammary artery (LIMA) to
left anterior descending artery (LAD), saphenous vein graft (SVG) to
main major-obtuse marginal branch (OM) and SVG to right coronary
artery posterior descending artery (RPDA). He had similar less intense
episode in 2010. The exercise stress test was positive and coronary angiography showed a patent LIMA–LAD, patent SVG–RPDA and moderate
disease at the mid SVG–OM with poor distal run-off. He was treated
medically at that time. For this index event, he underwent coronary angiography via the right femoral artery. There were severe native triple
vessel disease, patent LIMA–LAD, signiﬁcant lesions at proximal and
mid-distal ectatic SVG–OM and a subtotally occluded SVG–RPDA with
Thrombolysis in Myocardial Infarction (TIMI) 1 ﬂow at best (Fig. 1). A
6F MP1 guiding catheter (GC) was used to engage the SVG–RPDA. An
uninﬂated 2.5 × 10 mm semi-compliant balloon was passed down the
SVG–RPDA and followed by mechanical aspiration with Export AP Aspiration Catheter (Medtronic Inc., Minneapolis, USA). Repeated runs of
aspiration yielded some whitish debris. After improvement to TIMI 2
ﬂow, the culprit lesion at prox-mid of SVG–RPDA was inﬂated with
⁎ Tel.: +60 82 668111; fax: +60 82 455451.
E-mail address: [email protected].
the 2.5 × 10 mm balloon to facilitate the deployment of a 3.0 × 28 mm
ABSORB (Abbott Vascular, Santa Clara, USA) bioresorbable vascular
scaffold (BVS). The BVS was postdilated with a 3.5 × 15 mm noncompliant balloon to ensure good scaffold apposition.
When he came back 1 month later for clinic visit, he described
occasional niggling chest discomfort and he requested for percutaneous
coronary intervention (PCI) to the SVG–OM before taking up another
transcontinental project. A 7F LCB GC was used to intubate the SVG–
OM. Inadequate landing zone did not permit the use of distal protection
device. The proximal lesion was predilated with a 2.5 × 10 mm semicompliant balloon but the same balloon could not cross the stenotic
mid-distal SVG–OM. Hence, a smaller 1.5 × 15 mm balloon managed
to predilate this lesion followed by further predilatation with the
2.5 mm balloon. 2 overlapping STENTYS (STENTYS SA, Paris, France)
self-apposing drug eluting coronary stents were deployed at the ectatic
mid-distal SVG–OM. A 3.5–4.5 × 22 mm STENTYS stent was delivered
with ﬁrm and constant pressure to the distal SVG–OM and deployed
slowly to avoid forward jump of the self-expandable stent. Then, a
3.0–3.5 × 22 mm STENTYS stent was deployed in a similar fashion to
overlap with the distal STENTYS stent. The deployed STENTYS stents
were postdilated gradually with 4.0 × 12 mm and 5.0 × 12 mm noncompliant balloons to reduce the incidence of distal embolisation. As
for the proximal lesion, it was stented with a 2.75 × 15 mm Xience
Prime stent (Abbott Vascular, Santa Clara, USA). Final angiography
revealed an excellent result with improvement of the myocardial
blush grade. He was event free up to 1 year later.
As the patient had a recent acute coronary syndrome episode, the
subtotally occluded SVG–RPDA was potentially salvageable. After several runs of mechanical thromboaspiration which helped to improve the
TIMI ﬂow and yielded minimal whitish debris, things were kept simple
with subsequent balloon predilatation and stenting without the usage
of distal embolic protection device as the operator opined that the risk
of distal embolisation was low. BVS offers the option of providing
temporary scaffolding to overcome the coronary lumen narrowing
and once resorbed, it also restores the coronary vasomotion milieu [1].
Thus, similar beneﬁcial effects of BVS maybe endowed onto the vein
graft. There was only one prior published use of BVS in SVG before
this case and it was successfully done [2]. There were 3-month followup with cardiac computed tomographic angiography (CCTA) and optical
coherence tomography imaging which revealed patent BVS. [2,3] From
the CCTA, BVS permitted clear imaging results without the blooming
artifacts of metallic stents [2].
http://dx.doi.org/10.1016/j.ijcard.2014.08.043
0167-5273/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article as: Yew KL, Novel use of absorb bioresorbable vascular scaffold and STENTYS self-apposing coronary stent for complex
saphenous vein grafts intervention, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.08.043
e2
K.L. Yew / International Journal of Cardiology xxx (2014) xxx–xxx
Fig. 1. Initial angiography of the saphenous vein graft (SVG)–right posterior descending artery (RPDA) (A). There was very slow ﬂow of TIMI 1 grade down the SVG–RPDA (white arrows)
(B). Thromboaspiration helped to improve the TIMI ﬂow and revealed prox-mid SVG–RPDA culprit lesion (white arrows) (C). A 3.0 × 28 mm ABSORB bioresorbable vascular scaffold was
successfully deployed in the SVG–RPDA (white arrows) (D). Angiography of the SVG to main major-obtuse marginal branch (OM) which revealed critical proximal stenosis and diseased
ectatic mid-distal graft segment (E). The ﬁrst 3.5–4.5 × 22 mm STENTYS self-apposing stent was positioned at the distal SVG–OM segment (white arrow) (F). A second 3.0–3.5 × 22 mm
STENTYS stent (white arrow) was overlapped with the distal STENTYS stent (G). Final angiography of the SVG–OM which showed excellent angiographic result of the STENTYS stents and
2.75 × 15 mm Xience Prime stent (white arrow) and improved myocardial blushing (H).
The SVG–OM was a severely degenerated graft with concomitant
similarly diseased native left circumﬂex artery and OM vessel. After
discussion with the patient, we decided upon SVG–OM intervention
solely for symptom relief. The degenerated SVG–OM graft had technically challenging stenotic lesions and big ectatic segment. Conventional
balloon-mounted stents are tubular structures which would not appose
well for ectatic aneurysmal segment with large size discrepancy,
and may in fact increase the risk of stent thrombosis. However, newer
generation of self-expandable stent can overcome this limitation [4].
STENTYS stents have been described to treat bifurcation and ectatic aneurysmal coronary lesions but there is a lack of published data regarding
its use in vein graft intervention [4–7]. STENTYS stent is made from
nitinol with nickel–titanium alloy and would self-expand and conform
to the vessel lumen over time. However, the longer and bigger sized
STENTYS stent has lower proﬁle especially for traversing a generated
vein graft. Hence, the operator used a 7F LCB GC for better GC support
and maneuvered it to power position to facilitate the delivery of
STENTYS stents. Inadequate landing zone did not permit the use of distal
protection device. The deployment of the stent was done carefully to
avoid a forward jump complication of the device [7]. The second
STENTYS stent was minimally overlapped with the distal STENTYS
stent with the aid of platinum radio-opaque end markers under ﬂuoroscopic guidance (Fig. 1). Despite its self-apposing characteristic, it is still
prudent to perform postdilatation to ensure optimal stent strut apposition [4,6,7].
The application of BVS and STENTYS for vein graft PCI has been rarely
described and this case is the ﬁrst to use two different new stent
technologies for complex saphenous vein graft intervention. Perhaps
we now have the solution to tackle with conﬁdence the unmet needs
of various challenging saphenous vein graft lesions.
Conﬂict of interest
The authors report no relationships that could be construed as a
conﬂict of interest.
References
[1] Onuma Y, Serruys PW. Bioresorbable scaffold. The advent of a new era in percutaneous coronary and peripheral revascularization? Circulation 2011;123(7):779–97.
[2] Ong PJ, Jafary FH, Ho HH. “First-in-man” use of bioresorbable vascular scaffold in
saphenous vein graft. EuroIntervention 2013;20(9(1)):165.
[3] Roleder T, Parma Z, Smolka G, Ochała A, Wojakowski W. Optical coherence tomography imaging of everolimus-eluting bioresorbable vascular scaffold implanted into
coronary vein graft at 3-month follow-up. Eur Heart J 2014 Apr 10. http://dx.doi.
org/10.1093/eurheartj/ehu140.
[4] Moretti C, Omedè P, Presutti DG, et al. Shaping an ectatic coronary artery: Stentys
implantation. Int J Cardiol 2014;171(3):459–61.
[5] Laborde JC, Borenstein N, Behr L, Ramcharitar S. Stentys coronary bifurcation stent.
EuroIntervention 2007;3(1):162–5.
[6] La Manna A, Geraci S, Tamburino C. A self-expandable coronary stent system to treat
complex coronary stenosis complicated by poststenotic aneurysm: an optical coherence tomographic evidence-based case report. J Invasive Cardiol 2011;23(12):
E277–80.
[7] Giordano A, Corcione N, Polimeno M, et al. No surprising forward jump when
deploying a self-expandable stent: two cases exploiting the combination of
Emboshield Nav6 BareWire and Stentys devices. Int J Cardiol 2013;168(3):3079–81.
Please cite this article as: Yew KL, Novel use of absorb bioresorbable vascular scaffold and STENTYS self-apposing coronary stent for complex
saphenous vein grafts intervention, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.08.043

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