“Full bioresorbable jacket”: Alternative to very long segment metallic stenting in a young patient with diffuse coronary artery disease

“Full bioresorbable jacket”: Alternative to very long segment metallic stenting in a young patient with diffuse coronary artery disease

    “Full bioresorbable jacket:” alternative to very long segment metallic stenting in a young patient with diffuse coronary artery disea...

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    “Full bioresorbable jacket:” alternative to very long segment metallic stenting in a young patient with diffuse coronary artery disease Daniel Robaei MBBS, FRACP, Alastair Carlyle MBBS, FRACP, Nigel Jepson MBBS, FRACP, FCSANZ PII: DOI: Reference:

S0167-5273(16)31885-X doi: 10.1016/j.ijcard.2016.08.179 IJCA 23446

To appear in:

International Journal of Cardiology

Received date: Accepted date:

23 July 2016 7 August 2016

Please cite this article as: Robaei Daniel, Carlyle Alastair, Jepson Nigel, “Full bioresorbable jacket:” alternative to very long segment metallic stenting in a young patient with diffuse coronary artery disease, International Journal of Cardiology (2016), doi: 10.1016/j.ijcard.2016.08.179

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ACCEPTED MANUSCRIPT “Full bioresorbable jacket:” alternative to very long segment

Title:

metallic stenting in a young patient with diffuse coronary artery

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disease

Full bioresorbable jacket

Authors:

Daniel Robaei1,2 MBBS FRACP; Alastair Carlyle1 MBBS FRACP;

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Short title:

Affiliations:

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Nigel Jepson1,2 MBBS FRACP FCSANZ

1) Eastern Heart Clinic, Prince of Wales Hospital

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Randwick NSW 2031 Sydney, AUSTRALIA 2) University of New South Wales

coronary artery disease, percutaneous coronary intervention,

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Keywords:

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Randwick NSW 2031, Sydney, AUSTRALIA

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bioabsorbable devices, bioabsorbable stent, drug-eluting stent Imaging multidetector CT

Correspondence:

Dr Daniel Robaei Eastern Heart Clinic PO Box 746 Randwick NSW, AUSTRALIA 2031 [email protected]

ACCEPTED MANUSCRIPT A 36 year old male smoker with a background of recently diagnosed hyperlipidemia, and a family history of premature coronary artery disease presented with chest

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tightness on mild exertion occurring over the preceding week. Cardiovascular examination, electrocardiograph and serial troponin measurement in hospital were

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unremarkable, and transthoracic echocardiography was normal. Given the classical nature of the symptoms the patient proceeded directly to invasive coronary angiography which revealed significant long segment mid and distal stenosis of the

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LAD (Figure 1 Panel A-D).

Revascularization options were discussed. Left internal mammary grafting was deemed unlikely to produce an acceptable result due to the diffuse nature of the

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stenosis and the small luminal caliber. Given the patient’s very young age

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percutaneous revascularization with conventional metallic stents was avoided. The patient underwent successful percutaneous intervention of a long segment of the LAD

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using three Absorb bioresorbable vascular scaffolds (Abbott Vascular, Santa Clara,

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USA). Pre-inflation was performed with 2.5 and 3.0 mm non-compliant balloons to ensure adequate lesion preparation. 3.0x28mm and 2.5x28mm Absorb bioresorbable vascular scaffolds (BVS) were deployed with minimal overlap to the mid and distal LAD and a further 2.5x18mm Absorb BVS was deployed more distally to the LAD at the apex. All scaffolds were post-dilated with non-compliant balloons to 20 atmospheres within the scaffold expansion limits. The final angiographic result was satisfactory (Figure 1 Panel E-F) and the patient was discharged home with a plan to continue aspirin and prasugrel for twelve months.

ACCEPTED MANUSCRIPT The patient experienced atypical chest pain and re-presented to hospital, with followup invasive coronary angiography and computed tomography (CT) coronary

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angiography at 3 and 20 months respectively showing widely patent scaffolds and no significant residual coronary artery disease (Figure 2). There was no evidence of

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myocardial ischaemia on outpatient functional testing and no clinical events to three years follow up.

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Coronary revascularization in young patients necessitates an approach which

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considers the long term likelihood of future disease progression and need for target vessel revascularization. The case presented highlights a difficult management

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challenge with the diffuse nature of the atherosclerosis rendering the LAD unsuitable for grafting, and not ideally suited to percutaneous intervention with conventional

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metallic stents.

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Permanent metallic caging would be associated with a high probability for future

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target lesion revascularization and would remain a nidus for stent thrombosis, and instent restenosis through neointimal hyperplasia, stent fracture and neoatherosclerosis. A full metal jacket would also limit future revascularization options by precluding bypass grafting, and could act as an impediment to future percutaneous intervention by limiting luminal gains through the need for metal-in-metal at the time of reintervention.

Percutaneous intervention with multiple long-segment bioresorbable scaffolds was deemed the optimal management strategy. Complete revascularization would be achieved in the short term while in the long term resorption of the scaffolds would

ACCEPTED MANUSCRIPT maintain the possibility of future bypass grafting if required. Future percutaneous intervention to the target lesion would be possible without the need for metal-in-metal

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which would limit luminal gain. Additionally, resorption of the bioresorbable jacket would allow restoration of vasomotion, and positive expansile remodeling of the

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artery thereby maximizing late luminal gain (1). The use of bioresorbable rather than metallic stents would also allow for accurate non-invasive imaging by CT

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angiography.

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Bioresorbable scaffolds represent an advance in percutaneous coronary intervention, providing the acute local drug delivery and temporary mechanical support of metallic

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drug-eluting stents within the first 12 months (2). Complete scaffold resorption occurs 2-3 years after implantation thereby eliminating permanent caging of the treated

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vessel late after revascularization. While registry data and clinical trial data evaluating the Absorb bioresorbable scaffold have been promising (3-9), precise guidelines for

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use of the device over a metallic drug-eluting stent have not been established.

The case presented demonstrating revascularization of a diffusely diseased artery in a young patient is a particularly strong indication for use of bioresorbable scaffolds over metallic stents. The patient’s very young age necessitated consideration of a long-term revascularization strategy taking into account the likelihood of progression of atherosclerosis and the need for recurrent target vessel revascularization through percutaneous intervention or coronary bypass grafting. The patient underwent successful revascularization with no clinical events during follow-up to three years. Non-invasive imaging by CT angiography was feasible, and along with invasive

ACCEPTED MANUSCRIPT angiography, confirmed excellent luminal preservation of the lengthy treatment

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segment.

ACCEPTED MANUSCRIPT REFERENCES

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ACCEPTED MANUSCRIPT FIGURE LEGEND

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Figure 1: Panel A-D showing significant stenosis of a long segment of the mid and distal LAD (arrowheads). Panel E-F final angiographic result following implantation

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of three BVS in the mid and distal LAD

Figure 2: Panel A-B: Follow-up coronary angiography 3 months post BVS

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implantation showing a widely patent LAD. Panel C-D: Follow-up CT coronary

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angiography at 20 months. Panel C: patent LAD BVS with platinum markers (red

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arrows). Panel D: 3D reconstruction showing widely patent LAD (white arrows)

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Fig. 1

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