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A 67-year-old male patient with stable angina, hypertension and hypercholesterolemia who underwent bare metal stent (BMS) implantation in the distal right coronary artery (RCA) (Azule 3 × 9 mm) and everolimus-eluting stent (EES) implantation in the first diagonal branch (D1) (Xience 2.25 × 18 mm) and in the proximal circumflex branch (LCx) (Xience 3 × 28 mm). One year subsequent to the precedure the patient was readmitted for relapse of the angina Canadian Cardiovascular Society scale II, exhibiting a positive exercise test. The coronary angiography showed a distal-edge in-stent restenosis (ISR) in the distal RCA, extending to the posterior descending artery (PDA), Medina 110 bifurcation (Fig. 1A). Optical coherence tomography (OCT) showed predominantly fibrolipidic restenotic tissue, with minimal lumen area (MLA) 1.95 mm, minimal lumen diameter (MLD) 1.57 mm, proximal reference vessel diameter (RVD) 3.1 mm, distal RVD 2.75 mm and lesion length 21.2 mm (Fig. 1B, C). Optical coherence tomography-guided implantation of a bioresorbable scaffold (BRS) to treat the bifurcation ISR was performed through a radial approach, using a 6 french guiding-catheter. Guidewires were placed in the PDA and in the posterolateral artery (PLA), in order to protect the side branch in case of an eventual occlusion. Predilation 1:1 with a non-compliant (NC) balloon 3.0 × 18 mm (16 atm) was performed until the balloon was completely expanded in angiography. A second OCT run verified fragmentation of restenotic tissue and sufficient luminal gain to ensure adequate scaffold expansion. A poly-lactide BRS (ABSORB 3 × 28 mm) was then slowly deployed at 12 atm, holding pressure for 60 s. Proximaloptimalization-technique with an NC-balloon 3.25 × 15 mm (16 atm) was then performed by placing the proximal edge of the distal marker of the balloon at the carina of the PDA-PLA bifurcation, with an optimal angiographic result (Fig. 1D). A final OCT pullback showed optimal apposition and expansion (MLA 5.3 mm/MLD 2.6 mm; Fig. 1E), structural integrity of the device and clear access to the PLA side branch through the scaffold struts (Fig. 1F). Three-month follow-up documented an optimal clinical and angiographical result (Suppl. Video 1). Poly-lactide BRS are supposed to resorb completely [1–5], depending on the specific device and on patient/local conditions. The resorption restores vasomotion and eventually normal endothelial INTERVENTIONAL CARDIOLOGY

cardiology journal

Challenging treatment of in-stent restenosis in a coronary bifurcation by implantation of a bioresorbable scaffold under optical coherence tomography guidance