Successful Stent-less Percutaneous Coronary Intervention of Chronic Total Occlusion by Ablation Devices in a Young Adult

Supported by the EuroIntervention Journal

Authors

Soichi Komaki¹, Kazumasa Kurogi¹, Nobuyasu Yamamoto¹, Koichi Kaikita²

Case summary

We performed a percutaneous coronary intervention (PCI) in a 38-year-old male with effort angina. The coronary angiography revealed a chronic total occlusion (CTO) at the ostial segment of the left anterior descending artery (LAD) (Figure A, B).

The coronary risk factors included only high lipoprotein. We planned a right femoral artery approach for cardiac catheterization. The left coronary artery was engaged with an 8Fr CL35 SH guide catheter and crossed with a guidewire. Intravascular ultrasound (IVUS) OptiCross (Boston Scientific, Natick, MA, USA) demonstrated a large plaque burden with superficial thrombus and eccentric fibrous plaque in the CTO proximal lesion and organized thrombus distally. Excimer laser coronary angioplasty (ELCA) was performed to avoid the risk of embolic complications during PCI. Laser athero-ablation was performed using a 1.7 mm Vitesse-Cos RX catheter (Spectranetics, Colorado Springs, CO) with an incremental energy setting, with 60 mJ / 40 Hz (Figure C).

The organized thrombus was vaporized by ELCA in an energy-intensity-dependent manner. The minimum lumen area (MLA) was 2.37 mm², plaque burden at the MLA site was 83.0%. A directional coronary atherectomy (DCA) catheter ATHEROCUT L (Nipro Corporation, Japan) was inserted in the proximal LAD (Figure D).

After performing 15 cuts using the DCA catheter at 0 to 3 atm to remove plaques in the proximal LAD, an angiogram subsequently revealed TIMI grade 3 coronary flow in the LAD. The catheter was removed, and the cutter nose cone was irrigated. No media or adventitia was identified in the pathology report. After the LAD ostial lesion was treated with a 3.0×15 mm cutting balloon (Wolverine, Boston Scientific, Natick, MA), this lesion was then treated with a 3.0×30 mm drug coating balloon (DCB) (SeQuent Please, B. Braun, Melsungen, Germany) (Figure E).

The final angiogram and IVUS revealed no residual stenosis in the proximal LAD, retained organized thrombus in the distally (Figure F), and final MLA and plaque burden were 8.16 mm² and 43.0%, respectively (Figure G).

Heparin was discontinued after laboratory tests, and dual antiplatelet therapy (DAPT) with aspirin (100 mg/day) and prasugrel (3.75 mg/day) was continued after PCI. The patient remained stable and did not have angina. He was discharged from the hospital 2 days post-procedure. A repeat angiography after one month showed thrombus dissolution (Figure H); he was then continuously treated with a single anti-thrombotic therapy and remained well 6 months later.

We minimized the effects of distal embolism by performing ELCA antecedent to DCA. This strategy was adopted because drug-eluting stents may pose potential risks (stent thrombosis or bleeding by anti-thrombotic therapy) due to the permanent presence of foreign material in the coronary artery¹. Moreover, DCA and DCB therapy demonstrated clinical efficacy, safety, and feasibility². This strategy using a combination of ELCA, DCA, and DCB resulted in a clear, smooth, and stent-less lumen, minimizing the need for long-term antiplatelet therapy due to stent implantation. This is a novel PCI strategy for young adult patients with CTO.

Supplementary Material

Conflict of interest statement

None of the authors has relevant conflict of interest to disclose.

References

1. Philip F, Stewart S, Southard JA. Very late stent thrombosis with second generation drug eluting stents compared to bare metal stents: Network meta-analysis of randomized primary percutaneous coronary intervention trials. Catheter Cardiovasc Interv. 2016;88(1):38-48.
2. Kitani S, Igarashi Y, Tsuchikane E, et al. Efficacy of drug-coated balloon angioplasty after directional coronary atherectomy for coronary bifurcation lesions (DCA/DCB registry). Catheter Cardiovasc Interv. 2021;97(5):E614-E623.

Affiliations

1. Department of Cardiovascular Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan
2. Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan