A case of a de-novo lesion in the left circumflex artery treated with excimer laser and drug-coated balloon under the guidance of optical frequency domain imaging

摘要

A 72-year-old man who previously underwent percutaneous coronary intervention with a drug-eluting stent implantation from the left main trunk and extending to proximal left anterior descending artery was admitted to the documented hospital for angina pectoris. Coronary angiography (CAG) revealed 90% stenosis at the ostium of the left circumflex artery (LCX) (Fig. 1A). Excimer laser coronary angioplasty (ELCA) was performed using a 0.9 mm concentric laser catheter at a pulse rate of 25 Hz and energy output of 45 mJ/mm2, 35 Hz and 55 mJ/mm2, and 45 Hz and 60 mJ/mm2 for a total of 5200 pulses and balloon angioplasty using a drug-coated balloon (DCB) under the guidance of optical frequency domain imaging (OFDI), which revealed fibrous plaque and eccentric severe calcification (Fig. 1B). After ELCA, minimum lumen area (MLA) increased from 1.4 mm2 to 2.6 mm2 (Fig. 1C) and on final OFDI to 3.9 mm2 along with minor plaque dissection (Fig. 1D). Final CAG demonstrated optimal result without flow limitation (Fig 1E). After discharge, no significant clinical events were reported. Eight months later, follow-up CAG and OFDI were performed. Follow-up CAG demonstrated no restenosis at the ostium of the LCX (Fig. 1F). OFDI showed that the MLA slightly decreased from 3.9 mm2 to 3.5 mm2 and that the minor dissection had clearly improved (Fig. 1G). The DCB is efficacious in de-novo coronary artery lesions [1], which mainly contributed to suppress the restenosis in this case; however, although OFDI after ELCA demonstrated a slight increase in MLA, ELCA might be attributed to the lesion debulking and modification leading to optimal balloon expansion. A similar mechanism was previously reported in the case of in-stent restenosis [2]. For acute myocardial infarction, the combined use of ELCA and DCB for de-novo coronary artery disease works synergistically to reduce restenosis [3]. Stent-less strategy employing ELCA and DCB may be an effective revascularization of large vessel denovo lesions, when traditional stent deployment is not a viable option.