International Journal of Cardiology 173 (2014) e67–e69

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International Journal of Cardiology

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Letter to the Editor

Bioresorbable scaffolding after drug-coated balloons: A new chapter ofthe “leave nothing behind” saga

Bernardo Cortese ⁎, Rodrigo Sebik, Romano Seregni, Pedro Leon SilvaInterventional Cardiology, A.O. Fatebenefratelli Milano, Italy

⁎ Corresponding author at: Interventional CardiologyBastioni di Porta Nuova 21, 20100 Milano, Italy. Tel./fax: +

E-mail address: bcortese@gmail.com (B. Cortese).

http://dx.doi.org/10.1016/j.ijcard.2014.03.1310167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved

a r t i c l e i n f o

Article history:

Received 4 February 2014Accepted 15 March 2014Available online 21 March 2014

Keywords:Drug coated balloonBioresorbable vascular scaffoldCoronary dissectionIn-stent restenosis

allows effective drug deployment at the lesion site without the need foradditional stenting and reducing the duration of dual antiplatelet treat-ment to 30 days. However, some drawbacksmay consist in acute vesselrecoil or major, flow-limiting dissections, all conditions that requiresubsequent scaffold implantation. In our case, we decided to treat thedissection with a BVS, given the properties of this device that will beentirely reabsorbed in 24 months, thus avoiding the creation of adouble layer of stent struts [3]. Little is known about the association of2 antirestenotic drugs with different properties and mechanismsof action, that theoretically could result in a toxic coronary effect.

An 81 year oldman, past smoker andwith a history of hypertension,was brought to our catheterization laboratory for recurrent symptomsof unstable angina. Four months before he underwent primary percuta-neous coronary intervention (PCI) with thrombus aspiration and 2 spotbare metal stenting (3.0/12 and 2.5/18 mm) of 2 tandem lesions ofthe right coronary artery (Fig. 1). The angiogram showed patent leftcoronary artery and subocclusion of both stents caused by diffuse in-stent restenosis (Fig. 2 and Video 1). After lesion predilatation with a2.5 mm balloon we adopted a strategy of PCI with second generationdrug-coated balloon (DCB) (Restore, Cardionovum, Germany). A 2.5/12 mm DCB was successfully deployed at the proximal lesion site,whereas the second lesion was approached with a 2.5/20 mm DCB.Subsequent angiography showed a type F NHLBI coronary dissectionwith impaired flow at the site of distal lesion (Fig. 3 and Video 2). Wethus implanted a 2.5/28 Absorb bioresorbable vascular scaffold (BVS)(Abbott Medical, USA), subsequently postdilated with a 3.0 noncompli-ant balloon, obtaining a good angiographic result (Fig. 4 and Video 3).Six months later, the patient underwent scheduled coronarography,that showed the patency of both lesions without signs of restenosis orvessel damage (Fig. 5 and Video 4).

Current European guidelines on myocardial revascularization give aClass IIa for the management of bare metal stent restenosis with DCB,but give no indication for BVS use [1]. Since the release of these guide-lines, several other studies have shown good medium and long termoutcome with DCB in this setting, thus a recently published expert

, A.O. Fatebenefratelli Milano,39 0263632210.

.

Position Paper gave a Class I indication in this setting [2]. This technology

However, recently the results of a registry were reported that testedthe association of the same drugs, without raising safety concernsbut rather showing a possible synergy [4]. Moreover, all currentlycommercialized DCB show how paclitaxel lasts up to 3 weeks in the

Fig. 1. Final angiogram of the first procedure, after double spot bare-metal stenting.

Fig. 2. Tight in-stent restenosis of both BMSs. Fig. 4. Final result after BVS implantation, with persisting contrast dye between thescaffold and vessel wall.

e68 B. Cortese et al. / International Journal of Cardiology 173 (2014) e67–e69

vessel wall, thus warranting very limited persistence of the 2 drugssimultaneously.

The results of this case show how BVS implantation after the failureof DCB angioplasty is feasible and safe given the good 6-month angio-graphic result; this option for in-stent restenosis management mightbe considered as a bailout strategy to avoid the creation of a doublelayer of stent struts, and should be tested in a dedicated study.

Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.ijcard.2014.03.131.

Fig. 3. Persisting coronary dissection (type F) after treatment with DCB.

References

[1] Wijns W, Kolh P, Danchin N, et al. Task force on myocardial revascularization of theEuropean Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), European Association for Percutaneous CardiovascularInterventions (EAPCI) Guidelines on myocardial revascularization. Eur Heart J2010;20:2501–55.

[2] Cortese B, Berti S, Biondi-Zoccai G, et al. Drug-coated balloon treatment of coronaryartery disease: a position paper of the Italian Society of Interventional Cardiology.Catheter Cardiovasc Interv Feb 15 2014;83:427–35.

Fig. 5. Scheduled 6-month angiogram that shows patency of the right coronary arterywithout signs of in-stent restenosis or vessel damage.

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[3] Onuma Y, Serruys PW, Perkins L, et al. Intracoronary optical coherence tomographyand histology at 1 month and 2, 3, and 4 years after implantation of everolimus-eluting bioresorbable vascular scaffolds in a porcine coronary artery model: anattempt to decipher the human optical coherence tomography images in theABSORB trial. Circulation 2010;122:2288–300.

[4] Basavarajaiah S, Latib A, Hasegawa T, et al. Assessment of efficacy and safety of com-bining “paclitaxel” eluting balloon and “limus” eluting stent in the same lesion. JInterv Cardiol 2013;26:259–63.