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Images in CAD 437

Images in CAD Coronary Artery Disease 2017, 28:437–439

First-in-man demonstration of complete bioresorbable vascular scaffold resorption after treatment of in-stent restenosis Elisabetta Moscarellaa, Alfonso Ielasic, Bernardo Cortesed, Maria C. De Angelisb and Attilio Varricchiob, aDepartment of Cardiothoracic Sciences, Second University of Naples, Presidio Ospedaliero ‘Monaldi’, Azienda Ospedaliera Dei Colli, bLaboratory of Invasive Cardiology, Santa Maria della Pietà Hospital, Nola, Napoli, cCardiology Division, Ospedale Bolognini, ASST Bergamo Est and dInterventional Cardiology, ASST Fatebenefratelli-Sacco, Milano, Italy Correspondence to Elisabetta Moscarella, MD, Department of Cardiothoracic Sciences, Second University of Naples, Napoli 80100, Italy Tel/fax: + 39 081 706 2683; e-mail: [email protected]

Although drug-eluting stents (DES) promised to eliminate in-stent restenosis (ISR), treatment of DES-ISR is particularly challenging. Recently, interest has been shown on the use of bioresorbable vascular scaffold (BVS, Absorb; Abbott Vascular, Santa Clara, California, USA) as an appealing alternative to DES or drug-eluting balloon for ISR treatment [1], but to date there is no evidence of complete BVS resorption when used in ISR lesions. In February 2012, a 74-year-old-man with hypertension, hypercholesterolemia, and also a smoker presented with non-ST elevation myocardial infarction (NSTEMI). Angiography showed a severe stenosis at mid-right coronary artery (RCA) and percutaneous coronary intervention with three DES (resolute integrity 4.0 × 15 mm2, 3.5 × 12 mm2, and 3.5 × 18 mm2) was performed. After 3 days he was discharged in good clinical conditions, on dual antiplatelet therapy with maintained ejection fraction. In December 2012, he was admitted to our institution with NSTEMI, akinesia of the inferior wall with depressed ejection fraction of 45%. Angiography revealed critical DES-ISR. Unfortunately, intracoronary imaging was not performed but was based on the previous stent diameter and visual vessel estimation; after lesion predilatations, a 3.5 × 28 mm2 BVS was implanted, deployed through a standard stepwise balloon dilation (2 atm every 5″ up to a 30″ inflation up to 14 atm), postdilated with a 4.0 × 20 mm2 NC balloon; (Abbott Vascular, Santa Clara, California, USA) (Fig. 1c–e). Dual antiplatelet therapy with aspirin and ticagrelor was recommended for 12 months. At 6-month follow-up scheduled angiography showed good angiographic results. Intracoronary imaging Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.coronary-artery.com). 0954-6928 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

with optical coherence tomography (St. Jude Medical, St. Paul, Minnesota, USA) revealed some incomplete apposed struts with maximum strut incomplete apposition of 0.14 mm, left untreated (Fig. 1f). Struts reendothelialization was incomplete with the persistence of both uncovered struts (Fig. 1f and g) and alternated re-endothelialization struts (Fig. 1h and i). After 45 months the patient was asymptomatic on aspirin monotherapy. Angiographic control showed a persistent good result (Fig. 2a). Optical coherence tomography disclosed a nearly complete struts’ resorption with only few dissolved black boxes still present, representing an advanced degree of struts degradation (Fig. 2a and b, Supplementary Video 1, Supplemental digital content 1, http://links.lww.com/MCA/ A152). Longitudinal views in the lumen profile mode and in the L-mode, as well as the three-dimensional reconstruction (Fig. 2d–f), confirmed the good result with a minimal neointimal proliferation (minimal lumen area of 6.38 mm2) and showed a focal dilation distally to the previous implanted BVS (maximum vessel diameter: 5 mm). BVS technology represents a revolutionary concept in interventional cardiology. Thanks to the improvement in deployment procedure, leading to better outcomes, BVS use is rapidly increasing even in complex lesions. Despite representing an off-label indication, BVS has been proposed as an attractive alternative for ISR treatment, and it has shown good results in the long-term follow-up [1]. BVS indeed could theoretically overcome both DES and drug-eluting balloon limitations, allowing drug deliver and transient vessel support, avoiding the implantation of a further permanent metallic layer into the vessel. When implanted in de-novo coronary lesions, BVS loses mechanical integrity after 6–12 months and the resorption process completes in about 3–4 years [2]. However the complete BVS resorption after implantation in ISR lesions has not been reported yet. To the best of our knowledge we report the first comprehensive intracoronary imaging report, showing complete BVS resorption after ISR treatment. We speculate that when implanted following systematic procedural steps, BVS might be considered as an alternative ‘nostruts behind’ ISR treatment option.

Acknowledgements Conflicts of interest

There are no conflicts of interest. DOI: 10.1097/MCA.0000000000000505

Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.

438 Coronary Artery Disease 2017, Vol 28 No 5

Fig. 1

Coronary angiography of the right coronary artery and optical coherence tomography cross-sectional images at 6-month follow-up. (a) Severe midright coronary artery stenosis. (b) Final angiographic result after three DES implantation. (c) Severe proliferative DES-ISR. (d) BVS deployment in ISR (black arrows). (e) Final angiographic result after BVS deployment. White dotted lines indicate the DES implanted sites. Red dotted line indicates the BVS implanted site. (f, g) 6-Month OCT images showing incomplete BVS strut apposition (red arrows) and uncovered BVS struts (white arrows) alternated with well re-endothelialization BVS struts within the previous DES. (h, i) Well covered BVS struts. BVS, bioresorbable vascular scaffold; DES, drug-eluting stents; ISR, in-stent restenosis.


BVS for in-stent restenosis Moscarella et al. 439

Fig. 2

Coronary angiography and OCT cross-sectional images with longitudinal and three-dimensional (3D) reconstruction. (a) 45-Month angiographic follow-up showing a good long-term result. (b, c) OCT cross-sectional images showing complete struts’ resorption (b) and dissolved black boxes. (d, e) Longitudinal views in the lumen profile mode (d) and in the L-mode (e). (f) 3D reconstruction. OCT, optical coherence tomography. Focal dilation distally to the previous implanted BVS (white arrows).

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