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  • J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S VO L . 8 , N O . 8 , 2 0 1 5

    ª 2 0 1 5 B Y T H E AM E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N DA T I O N I S S N 1 9 3 6 - 8 7 9 8 / $ 3 6 . 0 0

    P U B L I S H E D B Y E L S E V I E R I N C . h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . j c i n . 2 0 1 5 . 0 2 . 0 1 8

    IMAGES IN INTERVENTION

    Excimer Laser Angioplasty–Facilitated Fracturing of Napkin-Ring Peri-Stent Calcium in a Chronically Underexpanded Stent

    Documentation by Optical Coherence Tomography

    Da Yin, MD,*y Akiko Maehara, MD,*y Stephen Mezzafonte, MD,z Jeffrey W. Moses, MD,*y Gary S. Mintz, MD,* Richard A. Shlofmitz, MDz

    A 79-year-old man underwent stent implan-tation into a severely calcified proximalleft anterior descending coronary lesion (Figure 1) in December 2012 followed by restenting in March 2014 to treat in-stent restenosis (Figure 2), both without full balloon expansion. Optical coher- ence tomography (OCT) documented thick, peri- stent napkin-ring calcium. He was admitted for recurrent unstable angina in April 2014. After initial treatment with excimer laser coronary angioplasty (ELCA; 1.4 mm, Spectranetics Corporation, Colorado Springs, Colorado) using saline injection, fluence of 60 mJ/mm2, and frequency of 80 Hz, a balloon was fully expanded. OCT showed fracturing of peri-stent

    From the *Cardiovascular Research Foundation, New York, New York; yColum and zSt. Francis Hospital, Roslyn, New York. Dr. Maehara has received gran Boston Scientific and ACIST Medical Systems; and has received speaker’s fee

    Boston Scientific. Dr. Mintz has received grant support and is a consulta

    Dr. Shlofmitz is on the speakers bureaus of CSI, Janssen Pharmaceuticals, a

    reported that they have no relationships relevant to the contents of this pap

    Manuscript received February 19, 2015; accepted February 26, 2015.

    calcium and good stent expansion (Figure 3). This approach has been reported in the ELLEMENT (Excimer Laser LEsion Modification to Expand Non- dilatable sTents) registry (1); in the current case, we used OCT to document the mechanism behind this approach.

    ACKNOWLEDGMENTS The authors thank Fernando A. Sosa, MS, from St. Jude Medical for his assistance in image collection.

    REPRINT REQUESTS AND CORRESPONDENCE: Dr. Akiko Maehara, Cardiovascular Research Foundation, 111 East 59th Street, 12th Floor, New York, New York 10022. E-mail: [email protected]

    bia University Medical Center, New York, New York;

    t support from Boston Scientific; is a consultant for

    s from St. Jude Medical. Dr. Moses is a consultant for

    nt for Boston Scientific and Volcano Corporation.

    nd St. Jude Medical. Drs. Yin and Mezzafonte have

    er to disclose.

    mailto:[email protected] http://crossmark.crossref.org/dialog/?doi=10.1016/j.jcin.2015.02.018&domain=pdf http://dx.doi.org/10.1016/j.jcin.2015.02.018

  • FIGURE 1 Coronary Angiogram, December 2012

    Calcium appeared as radio-opaque bands on both sides of the lumen (A, A’) and circumferential (B, B’). A stent (2.75 � 22 mm) was post-dilated by a noncompliant balloon (3.0 � 9 mm, 22 atm) with a final 28% diameter stenosis (DS). Boxed areas in A and B are shown magnified in A0 and B0, respectively.

    FIGURE 2 Coronary Angiogram and OCT, March 2014

    An additional stent (3.5 � 12 mm) was implanted and post-dilated by a noncompliant balloon (4.0 � 9 mm, 26 atm) with a 39% final diameter stenosis (DS). Optical coherence tomography (OCT) showed diffuse circumferential calcium (white arrows) behind an underexpanded stent

    (white asterisks) with a pre-intervention minimum stent area of 2.75 mm2 and only mild intimal hyperplasia.

    Yin et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 8 , N O . 8 , 2 0 1 5

    ELCA Fracturing of Napkin-Ring Peri-Stent Calcium J U L Y 2 0 1 5 : e 1 3 7 – 9 e138

  • FIGURE 3 Coronary Angiogram and OCT, April 2014

    Matched OCT slices and longitudinal reconstruction showed a pre-excimer laser coronary angioplasty (ELCA) MSA of 2.26 mm2, no change

    post-ELCA (white arrow), but fracturing of the thinnest part of the calcium after balloon post-dilation with a noncompliant balloon

    (3.5 � 9 mm, 22 atm) resulting in good stent expansion (MSA ¼ 6.34 mm2) and a final DS of 10%. Abbreviations as in Figure 2.

    J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 8 , N O . 8 , 2 0 1 5 Yin et al. J U L Y 2 0 1 5 : e 1 3 7 – 9 ELCA Fracturing of Napkin-Ring Peri-Stent Calcium

    e139

    RE F E RENCE

    1. Latib A, Takagi K, Chizzola G, et al. Excimer laser lesion modification to expand non-dilatable stents: the ELLEMENT registry. Cardiovasc Revasc Med 2014;15:8–12.

    KEY WORDS calcium, excimer laser coronary angioplasty, optical coherence tomography

    http://refhub.elsevier.com/S1936-8798(15)00675-5/sref1 http://refhub.elsevier.com/S1936-8798(15)00675-5/sref1 http://refhub.elsevier.com/S1936-8798(15)00675-5/sref1 http://refhub.elsevier.com/S1936-8798(15)00675-5/sref1

    Excimer Laser Angioplasty–Facilitated Fracturing of Napkin-Ring Peri-Stent Calcium in a Chronically Underexpanded Stent Acknowledgments Reference