A case of effective repeated distal protection on acute and subacute phase PCI to occluded sirolimus-eluting stent in SVG

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概要

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• The case was 80 year-old male with diabetes and dyslipidemia. In 1993, he developed acute myocardial infarction and received percutaneous coronary intervention followed by triple coronary bypass grafting. 11 years after the surgery, bare metal stent (BMS) was implanted to narrowed saphenous vein graft (SVG) anastomosed to left circumflex. Repeated in-stent restenoses were recovered by BMS and sirolimus-eluting stent (SES) at 3 and 9 months after the first stenting, respectively. Seven years after SES implantation, he visited our hospital due to sudden chest pain at rest, and ECG on admission showed ST-segment depression at electrode V4–6. Emergent coronary angiography revealed subtotal occlusion of implanted SES in SVG. During IVUS imaging after thrombectomy, delayed blood flow in SVG was detected on angiography with decrease in systemic blood pressure. After the recovery of systemic conditions by repeated thrombectomy and intracoronary nicorandil administration, everolimus-eluting stent (EES) was directly implanted over SES with distal protection. Although ‘filter-no-reflow’ phenomenon appeared after the stenting, immediate removal of protection device resulted in a rapid recovery of coronary blood flow. IVUS showed insufficient stent expansion but minimal lumen area was sufficiently gained, therefore, angioplasty for bailout was exterminated without adjunctive dilations. Four days after the first session, implanted EES was adjunctively dilated with larger balloon under the distal protection. Although ‘filter-no-reflow’ re-occurred, systemic condition did not deteriorate and well-apposed stent was confirmed by IVUS. Interestingly, distal protection device in 2nd session caught as plenty of plaques as that in 1st session. Our experience suggests that distal protections should be always took into consideration in case of angioplasty to large vessels such as SVG, because angiogram and IVUS imaging sometimes can hardly predict occurrence of distal embolism during PCI.

著者

• 鈴木 ゆき

  西新井ハートセンター病院循環器内科

• 重城 健太郎

  西新井ハートセンター病院循環器内科

• 齊藤 克己

  西新井ハートセンター病院循環器内科

• 天野 宏

  西新井ハートセンター病院心臓血管外科

• 河合 靖

  西新井ハートセンター病院心臓血管外科

• 竹内 靖夫

  西新井ハートセンター病院心臓血管外科

関連論文

• A case of effective repeated distal protection on acute and subacute phase PCI to occluded sirolimus-eluting stent in SVG

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