Clinical
Stent-less percutaneous coronary intervention using rotational atherectomy and drug-coated balloon: A case series and a mini review

https://doi.org/10.1016/j.carrev.2018.02.007Get rights and content

Highlights

  • Coronary revascularization therapy under DES-unsuitable conditions remains to be established.

  • Rotational atherectomy followed by drug-coated balloon dilation alone is proposed as a choice.

  • Optical frequency domain imaging is useful during the stent-less procedure.

Abstract

Background

Experiences of rotational atherectomy (RA) followed by drug-coated balloon (DCB) dilation alone (RA/DCB) for de novo coronary artery lesion have been limited.

Case series

Case 1 (65 year-old male) with silent myocardial ischemia and hemodialysis had old anterior myocardial infarction and intact LM/LCx, and underwent RA/DCB against a diffuse calcified lesion in the proximal LAD and a tandem lesion in the proximal RCA. Case 2 (88 year-old female) with post-infarction unstable angina had severe thrombocytopenia and anemia due to myelodysplastic syndrome (platelet 6000/μL, hemoglobin 8.3 g/dL), and underwent RA/DCB against a severe stenosis in the mid LCx after transfusions. Case 3 (47 year-old male) with silent myocardial ischemia due to possible sequelae of Kawasaki disease underwent RA/DCB against a restenotic lesion at the in-let of the calcified aneurysm in the proximal LAD. In all of the patients, PCI was successfully completed under optical frequency domain imaging (OFDI) without complications. Follow-up CAG performed 6–7 months after the procedure revealed no restenosis in case 1 and case 3, and all of the 3 cases have been free of cardiovascular/hemorrhagic events for 11–37 months since the last stent-less procedures.

Conclusions

These cases suggest that RA/DCB under OFDI might be an alternative stent-less revascularization therapy of choice for patients who may be unsuitable for drug-eluting stent implantation.

Introduction

Implantation of drug-eluting stent (DES) has been a mainstay of the interventional treatment of coronary artery disease (CAD); however, there still remain several clinical conditions, in which DES implantation is inappropriate, such as calcified diffuse lesion, bleeding tendency, metal allergy, and coronary sequelae of Kawasaki disease (KD). For CAD patients under those specific status, percutaneous coronary intervention (PCI) without stenting “stent-less PCI” is theoretically a suitable revascularization therapy. Nowadays drug-coated balloon (DCB) for de novo coronary artery lesions has attracted more attention, and pre-treatment with rotational atherectomy (RA) followed by DCB dilation (RA/DCB) might be a promising option of stent-less PCI [[1], [2], [3]]. In this mini-review, we have focused on utility of the stent-less PCI using RA/DCB under the DES-unsuitable conditions in a case series.

Section snippets

Case 1: Calcified diffuse lesion in hemodialysis

Hemodialysis is an established risk factor of DES failure, such as target lesion revascularization (TLR) and late stent thrombosis [4,5], and calcified diffuse lesion is one of the characteristics of coronary involvement in patients with hemodialysis.

A 65-year-old man with silent myocardial ischemia and hemodialysis had old anterior myocardial infarction, a calcified diffuse lesion in the proximal left anterior descending coronary artery (LAD), a tandem lesion in the proximal right coronary

Discussion

As a primary interventional treatment for in-stent restenosis, usefulness of DCB has already been established [12]. In contrast, for de novo coronary artery lesions, no proved facts supporting superiority of DCB over DES have been available; however, several registries and small-sized randomized controlled trials comparing with DES have indicated acceptable results regarding safety and efficacy of DCB particularly among small vessel de novo lesions [[13], [14], [15], [16]]. In the DCB-alone

Conclusion

Stent-less PCI using RA followed by DCB dilation under OFDI could be a candidate of revascularization therapy for CAD patients complicated with DES-unavailable conditions.

The following are the supplementary data related to this article.

. Case 1 Pre-procedural (Panel A, B, equivalent to Panel I, J in Fig. 2, respectively), post-ablation with 1.75 mm burr (Panel C, D, corresponding to Panel A, B, respectively), post-ablation with 2.0 mm burr (Panel E, F, corresponding to Panel A, B, respectively),

Disclosures

The authors have no conflicts of interest regarding the content of the manuscript.

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