Excerpt

A 65-year-old woman was previously treated with drug eluting stent (Resolute 3.5/12 mm Medtronic, Minneapolis, MN, USA) implantation in ostial LM with a satisfactory final result at optical coherence tomography (OCT) imaging (Fig. 1A). Six months later she was admitted because of unstable angina and coronary angiograms revealed a severe de novo mid left anterior descending (LAD) stenosis (Fig. 1B). Unexpectedly, after wiring the LAD stenosis with a 0.014’’ floppy wire, the stent was unable to progress through the LM to the distal lumen. OCT imaging revealed that the wire had entered the LM between the struts and the vessel wall (area of stent malapposition), finally re-entering the stent luminal area (Fig. 1C–E). The OCT 3D reconstruction clearly depicted this scenario (Fig. 1E*). To gain access to the true stent lumen, an IVUS probe was advanced to guide LM re-wiring showing a severe LM stent compression with an MLA of 4.3 mm² (Fig. 1E***). To stabilize the coaxial system, facilitate wire control and gain access to the endoluminal portion of the stent, a double lumen microcatheter (Crusade, Kaneka Corp., Tokyo, Japan) was advanced over the pre-existing wire (Fig. 1F) and a second wire was manipulated with IVUS guidance and positioned in the distal LAD. The LM stent was subsequently dilated with 4.0/15 mm noncompliant balloon with a good IVUS final result (Fig. 1G). Thus, the stenosis in the mid LAD was successfully treated with a provisional stenting technique delivering a 3.0/12 mm DES (SYNERGY II; Boston Scientific Corporation), with a kissing balloon dilatation (Fig. 1H).

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