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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 97-99

Percutaneous coronary intervention of the large right coronary artery using a renal stent – An off-label device for an on-label indication


1 Consultant Interventional Cardiologist, Department of Cardiology, Yashoda Super Speciality Hospitals, Raj Bhavan Road, Somajiguda, Hyderabad, Telangana, India
2 Consultant General Physician, Indira Nursing Home, Ramnagar, Hyderabad, Telangana, India

Date of Submission19-Jan-2020
Date of Decision18-Mar-2020
Date of Acceptance25-Mar-2020
Date of Web Publication25-Sep-2020

Correspondence Address:
Dr. Pankaj Jariwala
Yashoda Hospitals, Raj Bhavan Road, Somajiguda, Hyderabad - 500 082, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JICC.JICC_2_20

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  Abstract 


Percutaneous coronary intervention of large ectatic coronary arteries is always challenging for the interventional cardiologist. Large coronary arteries, also called as “dilated coronaropathy,” have heterogeneous etiology that angiographically manifests as localized or diffuse ectasia. The large caliber of the coronary artery poses many challenges such as the choice of type of the stent whether to use coronary versus noncoronary stent or drug-eluting versus bare-metal stent. Furthermore, the size of the stent and complete expansion after its deployment can be addressed using intracoronary imaging techniques such as intravascular ultrasound and optical coherence tomography in the setting of coronary artery ectasia. Different types of peripheral vascular or nonvascular stents were used for the percutaneous treatment of large native coronary arteries or saphenous vein graft lesions. We report a case, where a renal stent for a large coronary artery was used successfully to treat the clinical situation. Furthermore, we have discussed the various options of the percutaneous therapy available in the setting of large coronary arteries as described in the literature.

Keywords: Coronary artery disease, coronary artery ectasia, percutaneous transluminal coronary angioplasty, renal stent


How to cite this article:
Jariwala P, Reddy MA. Percutaneous coronary intervention of the large right coronary artery using a renal stent – An off-label device for an on-label indication. J Indian coll cardiol 2020;10:97-9

How to cite this URL:
Jariwala P, Reddy MA. Percutaneous coronary intervention of the large right coronary artery using a renal stent – An off-label device for an on-label indication. J Indian coll cardiol [serial online] 2020 [cited 2020 Oct 24];10:97-9. Available from: https://www.joicc.org/text.asp?2020/10/2/97/296120




  Introduction Top


Large coronary artery or “dilated coronaropathy” could be secondary to focal or diffuse coronary ectasia or aneurysmal dilatations.[1] Atherosclerosis is the most common etiology for the development of such an abnormal dilatation of coronary arteries.[2] The development of stenotic lesions in ectatic coronary arteries sometimes poses a challenge to the interventional cardiologist due to a very large size of the vessel and nonavailability of larger sizes of coronary stents while performing a percutaneous coronary intervention (PCI), particularly in an emergency situation such as acute coronary syndrome.


  Case Report Top


A 68-year-old male admitted with complaints of shortness of breath on exertion New York Heart Association (NYHA) class III for last 2 weeks. He was reformed smoker and hypertensive on regular treatment. Electrocardiography showed left ventricular hypertrophy with 2 mm ST-segment depression in inferolateral leads. Echocardiography revealed mild left ventricular dysfunction (ejection fraction 45%) with hypokinesia of the inferior wall with concentric left ventricular hypertrophy. Troponin T-level was elevated. Coronary angiography showed normal left coronary system, but there was critical ostial stenosis of the very large right coronary artery (RCA) (5.69 mm) with thrombolysis in myocardial infarction (TIMI) 2 flow.

As PCI was indicated in view of the acute coronary syndrome, the very large size of the RCA raised a concern related to the size of the stent. We discussed the various options of plain balloon angioplasty, use of balloon-expandable peripheral/renal stent, and self-expanding stents. PCI of the ostial lesions needs greater radial strength as it had a tendency for recoil. Hence, we considered for the use of balloon-expandable stent.

7Fr Judkins right catheter guide catheter was engaged and sequential dilatation of the critical stenosis was done using 2.0 mm × 10 mm, 2.5 × 15 mm, and 3.5 mm × 15 mm balloons. The 6.0 mm × 24 mm express vascular LD stent was deployed to the ostio-proximal segment of the RCA. There was 30% under expansion at the lesion site, which was dilated further using the same stent balloon after partially pulling out of the ostium of the RCA with the purpose of the simultaneous ostial flaring at a higher pressure. The end result was gratifying with the establishment of TIMI 3 flow. He was discharged uneventfully on dual antiplatelet therapy, statin, Angiotensin converting enzyme (ACE) inhibitor, and beta-blocker. Furthermore, there was an improvement in the symptoms during 8-month follow-up [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f.
Figure 1: (a-f) Coronary angiography of the RCA showed a critical stenosis of the ostio-proximal segment [white arrow, a] which measured at the ostium 5.69 mm. The critical lesion was predilated using 1.5 mm, 2.0 mm, 2.5 mm balloons (d). The 6.0 x 18 mm renal stent was deployed across the lesion [dashed arrow, c]. The osteal flaring was done using the stent balloon (d and e). Final angiography of the RCA revealed brisk TIMI III flow with no residual stenosis, dissection (f)

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  Discussion Top


Although the coronary artery ectasia is defined as 1.5 times dilatation than the reference normal diameter, there is no clear consensus about the definition of the very large coronary artery diameter like more than 4.5–5 mm.

Furthermore, there are no coronary stents available for very large diameter coronary arteries. There are various case reports of the use of peripheral stents or renal stents for the larger coronary arteries during the PCI. In 1993, Friedrich et al. have reported for the first time the investigational use of the Palmaz-Schatz biliary stent for the large saphenous vein graft lesions because during those days the available coronary stents had distortions upon >5.0 mm expansion.[3] They had 100% success (n = 6) for patients those underwent percutaneous therapy for the larger degenerated saphenous vein grafts and could expand stent up to 5–6 mm in their cases. Further Wong et al. compared the biliary stent versus coronary stents for the PCI of larger saphenous vein graft as biliary stents had better radial strength and good visibility. Although they had comparable results with a 95% success rate and 6-month event-free survival among the 80% of cases, those stents were less flexible and required technical operator experience for the deployment of biliary stents.[4] Agirbasli et al. used intratherapeutics intrastent, which is a slotted, tubular, balloon-expandable stent in larger ectatic coronary arteries in three patients.[5] These stents are used for the treatment of malignant biliary strictures and for its deployment as a coronary stent requires hand crimping on the larger peripheral balloon. Its deployment needs experience operator and chances of dislodgment and embolization should consider. Khanal et al. in their series compared the biliary nonvascular stents against the coronary stents, and those patients who received biliary stents had higher rates of minor and major complications. They used tubular-slotted biliary stents of the percutaneous treatment of larger saphenous vein grafts.[6]

Chio et al. also published their retrospective experience of Palmaz biliary stents for the PCI of the larger coronary arteries in 56 patients where they had 100% success rate and 11% clinical restenosis and 3-year event-free survival up to 80%.[7]

Rha et al. did a novel technique of parallel stenting by deploying two 3.5-mm stents parallel to each other in an ectatic coronary artery.[8] However, it was an index case report that needs larger experience to validate its routine use for doing PCI in larger ectatic coronary arteries, while Le et al. used peripheral self-expanding tapered carotid stents and embolic protection device in ectatic coronary arteries.[9] However, again we need more experience to evaluate the effectiveness and safety of tapered self-expanding stents, in the ectatic coronary arteries.

Ozeke et al. used >5 mm diameter renal stent for the PCI of the large coronary arteries in two patients and their both patients did well. They impressed upon maintaining the ratio of an artery to stent diameter of 1:1 while choosing stent. Post-dilatation of a smaller coronary stent using larger balloon may lead to overexpansion and thus leads to acute recoil as it alters the tensile properties of the stent.[10] Oh et al. did balloon angioplasty using larger balloon, whereas in another case they used renal stent similar to our case. They insist upon plain old balloon angioplasty in selected cases in these larger diameter coronary arteries, and the long-term patency is comparable to cases where large diameter stents were deployed.[10]

Pourdjabbar et al. reported a case series of four cases of larger (>6 mm) unprotected left main coronary artery angioplasty using renal stent, and they used intravascular ultrasound in all their cases to determine the reference vessel diameter and adequacy of stent apposition.[11]

In their retrospective study of PIC with renal (noncoronary) stent in larger coronary arteries and saphenous vein graft (≥4.5 mm) in 27 cases with a mean diameter of 5.2 mm, Harnett and Pourdjabbar et al. had only one case of target artery revascularization.[12] Bhatia et al. did primary angioplasty of the left anterior descending artery using 7-mm renal stent who presented with acute anterior wall myocardial wall infarction.[13]

Recently, one of the stent manufacturers launched 4.5 and 5 mm drug-eluting stents that can reach up to 5.75 mm postdilatation limit.[14] However, still, we do not have coronary stents for use in very large coronary arteries measuring >6 mm.

The deployment of the stent in larger coronary arteries should be justified for those lesions where medical therapy fails or critical ostial lesions as in our case or flow-limiting dissection after balloon angioplasty.


  Conclusion Top


Angioplasty of the large coronary arteries is always challenging, as the present available coronary devices cannot be advocated. Previous studies and case reports highlight the use of various innovative methods and techniques using different types of noncoronary stents. The experience of the operator is important in dealing with the obstructive lesions of the large coronary arteries. Whatever technique we follow for the revascularization, but one should adhere to the same guidelines for the PIC of coronary lesions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Krüger D, Stierle U, Herrmann G, Simon R, Sheikhzadeh A. Exercise-induced myocardial ischemia in isolated coronary artery ectasias and aneurysms (“dilated coronopathy”). J Am Coll Cardiol 1999;34:1461-70.  Back to cited text no. 1
    
2.
Mavrogeni S. Coronary artery ectasia: From diagnosis to treatment. Hellenic J Cardiol 2010;51:158-63.  Back to cited text no. 2
    
3.
Friedrich SP, Davis SF, Kuntz RE, Carrozza JP Jr, Baim DS. Investigational use of the Palmaz-Schatz biliary stent in large saphenous vein grafts. Am J Cardiol 1993;71:439-41.  Back to cited text no. 3
    
4.
Wong SC, Popma JJ, Pichard AD, Kent KM, Satler LF, Mintz GS, et al. Comparison of clinical and angiographic outcomes after saphenous vein graft angioplasty using coronary versus 'biliary' tubular slotted stents. Circulation 1995;91:339-50.  Back to cited text no. 4
    
5.
Agirbasli M, Morris DC, Marshall JJ. The use of intrastent peripheral stent in large coronary arteries: Report of three cases. Catheter Cardiovasc Interv 2000;50:498-501.  Back to cited text no. 5
    
6.
Khanal S, Scavetta K, Oh C, Abdel-Dayem T, Al-Zaibag M, Jutzy KR, et al. Immediate and long-term results comparing coronary versus biliary tubular-slotted stents to treat old obstructed saphenous vein grafts. Angiology 2000;51:647-57.  Back to cited text no. 6
    
7.
Chio FL, Liu MW, Al-Saif SM, Khan MA, Lawson D, Al-Mubarak N. Long-term clinical outcome after implantation of medium Palmaz (biliary) stents in very large native coronary arteries. Catheter Cardiovasc Interv 2002;56:35-9.  Back to cited text no. 7
    
8.
Rha SW, Wani SP, Oh DJ. Parallel stenting using two sirolimus-eluting stents in an ectatic coronary artery stenosis. Heart 2007;93:976.  Back to cited text no. 8
    
9.
Le V, Abu-Fadel M, Hennebry TA. The use of tapered self-expanding stents and embolic protection devices in the treatment of stenotic ectatic coronary arteries: A report of two cases. Catheter Cardiovasc Interv 2008;72:643-6.  Back to cited text no. 9
    
10.
Oh SK, Rha SW, Kook H, Kim DH, Ho SY, Kim SH, et al. Two different successful angioplasty methods in patients with stenotic coronary artery ectasia. Chonnam Med J 2012;48:185-9.  Back to cited text no. 10
    
11.
Pourdjabbar A, Hibbert B, Simard T, Ramirez D, Glover C, O'Brien E. RACER renal stents for large diameter left main coronary artery intervention. Int J Cardiol 2012;156:e68-70.  Back to cited text no. 11
    
12.
Harnett DT, Maze R, Pourdjabbar A, Ramirez FD, Simard T, Di Santo P, et al. Percutaneous coronary intervention with RACER renal stents in very large diameter coronary arteries. Int J Cardiol 2015;201:342-4.  Back to cited text no. 12
    
13.
Bhatia V, Arora P, Gupta R, Kaul U. Primary angioplasty using a renal stent in a severely ectatic and occluded left anterior descending coronary artery. Hear Res Open J 2016;3:16-8.  Back to cited text no. 13
    
14.


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