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Restenosis after excimer laser coronary atherectomy and drug-coated balloon dilation in Takayasu's arteritis: a case report and review of the literature.

ABSTRACT: Takayasu's arteritis (TAK) is a rare chronic granulomatous arteritis that mainly affects the aorta and its major branches. Coronary artery (CA) involvement can be observed in 10-25% of TAK patients. We report a 21-year-old young female who was previously diagnosed with TAK and severe left main coronary artery (LMCA) stenosis and underwent numerous percutaneous coronary interventions (PCIs) in our hospital due to in-stent restenosis (ISR). This time, an excimer laser coronary atherectomy (ELCA) and drug-coated balloon (DCB) dilation was taken at the LMCA for the ISR. The blood flow was smooth after the operation, and she was symptom-free after discharge. Unfortunately, 5 months later, severe intimal hyperplasia was still seen in the stent of LMCA and left anterior descending (LAD) coronary artery. A coronary artery bypass graft surgery (CABG) was performed, and she has been symptom-free ever since. ELCA plus DCB is one of the novel ways we first reported. However, ensuring long-term inflammation control is equally important to restore blood flow. The combination of revascularization and anti-inflammation/immunosuppression is recommended to improve the outcomes of TAK patients with CA involvements.

SUBMITTER: Liang S

PROVIDER: S-EPMC10413599 | biostudies-literature | 2023 Aug

REPOSITORIES: biostudies-literature

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Restenosis after excimer laser coronary atherectomy and drug-coated balloon dilation in Takayasu's arteritis: a case report and review of the literature.

Liang Shichu S Yang Jinming J Ma Min M Zhou Minggang M Liu Zhiyue Z Huang He H He Yong Y

Thrombosis journal 20230810 1

Takayasu's arteritis (TAK) is a rare chronic granulomatous arteritis that mainly affects the aorta and its major branches. Coronary artery (CA) involvement can be observed in 10-25% of TAK patients. We report a 21-year-old young female who was previously diagnosed with TAK and severe left main coronary artery (LMCA) stenosis and underwent numerous percutaneous coronary interventions (PCIs) in our hospital due to in-stent restenosis (ISR). This time, an excimer laser coronary atherectomy (ELCA) a ...[more]

PMID: 37563604

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Project description:BackgroundDrug-coated balloon angioplasty after directional coronary atherectomy (DCA) allows for a stentless strategy providing good short-term outcomes; however, late-phase restenosis and its mechanism remain unclear. Moreover, histopathological evaluation for late-phase restenosis post-drug-coated balloon angioplasty after DCA has never been reported.Case summaryWe report the first case of late-phase restenosis post-drug-coated balloon angioplasty after DCA, wherein tissue analysis using intravascular coronary imaging and histopathology suggested neovascularization in newly developed neointimal proliferation. A 52-year-old man with a history of dyslipidaemia presented with exertional angina pectoris. He underwent percutaneous coronary intervention (PCI) with drug-coated balloon angioplasty after DCA for the proximal left anterior descending artery. Although coronary angiography after nine months revealed no restenosis, he experienced recurrent chest discomfort after 25 months. Coronary angiography confirmed late-phase restenosis, and intravascular ultrasound showed progressively developed neointima above the underlying residual plaque. Optical coherence tomography suggested developing neovascularization within the neointima. Stentless PCI with drug-coated balloon angioplasty after DCA was re-performed, and collected restenotic sample. The histopathological evaluation confirmed less-cellular neointimal proliferation with rich neovascularization and concomitant diffuse vascular endothelial growth factor (VEGF) expression.DiscussionLate-phase restenosis post-drug-coated balloon angioplasty after DCA comprised less-cellular neointima, suggesting inhibition of cell proliferation by drug-coated balloon efficacy. However, diffuse VEGF expression and concomitant rich neovascularization with haemorrhage and inflammation might indicate neointimal proliferation. Further large-scale investigations of the restenotic mechanism should be performed to avoid long-term target vascular failure after drug-coated balloon angioplasty post-DCA.

Project description:BackgroundNeoatherosclerosis, a prominent contributor to in-stent restenosis (ISR), persists as a formidable challenge during percutaneous coronary intervention. Excimer laser coronary atherectomy (ELCA) and embolic protection devices may help reduce coronary flow disturbance from procedure-related distal embolization.Case summaryA 71-year-old man experienced in-stent neoatherosclerosis rupture-related non-ST segment elevation myocardial infarction. Multidisciplinary intracoronary imaging, including intravascular ultrasound and optical coherence tomography (OCT), suggested that the ISR was caused by a neoatherosclerosis rupture that can potentially lead to distal embolization. Excimer laser coronary atherectomy (fluence, 45 mJ/mm2 and frequency, 25 pulse/s) using a 1.7 mm concentric catheter was performed with distal protection using Filtrap (Nipro Corporation, Tokyo, Japan), which significantly reduced the volume of the neoatherosclerosis. However, subsequent ELCA on the highest setting (fluence, 60 mJ/mm2 and frequency, 40 pulse/s) led to a filter no-reflow phenomenon, although OCT revealed a further effective vaporization of the neoatherosclerosis and an apparent reduction of soft tissue compatible with the thrombus. After removing the embolic protection device, drug-coated balloon angioplasty provided optimal results without coronary flow disturbance.DiscussionExcimer laser coronary atherectomy reduces soft plaque and thrombus burden, which can reduce the occurrence of distal embolization in select cases. In the case of this patient, procedure-related distal embolization may have been induced by the heightened photomechanical effects resulting from the use of the highest setting in ELCA under increased intracoronary arterial pressure caused by continuous saline injection during ELCA. Concomitant distal protection during ELCA may be more feasible for preventing coronary flow disturbance in patients with a large amount of neoatherosclerosis.

Dataset Information

Restenosis after excimer laser coronary atherectomy and drug-coated balloon dilation in Takayasu's arteritis: a case report and review of the literature.

Publications

Restenosis after excimer laser coronary atherectomy and drug-coated balloon dilation in Takayasu's arteritis: a case report and review of the literature.

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