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Left main coronary artery stenosis is associated with dismal prognosis when untreated. Coronary artery bypass grafting (CABG) is the standard treatment. Although stent implantation is increasingly performed for de novo left main lesion, CABG is inevitable if in-stent restenosis (ISR) occurs. Recently, use of sirolimus eluting stents has proved effective in reducing restenosis in simple de novo lesions. We present a patient who underwent sirolimus eluting stent implantation for significant left main ISR involving the bifurcation.
The patient was a 60 year old woman who presented with exertional angina caused by isolated ostial left anterior descending artery (LAD) stenosis. Direct bare stent implantation was initially performed, but was followed by occurrence of diffuse ISR six months later. She was then treated by additional bare stent implantation (stent-in-stent), with the second stent across the left main coronary artery. Six months repeat coronary angiography showed recurrence of ISR with involvement of the distal left main coronary artery and ostial left circumflex (LCx) artery (below, left panel).
After sequential balloon predilation, two sirolimus eluting stents (Cypher, Cordis) were deployed in the left main LAD (3.0 × 18 mm) (parent vessel)/LCx (3.0 × 8 mm) (side branch) bifurcation lesion by T stent technique. The stents were post-dilated with kissing balloon angioplasty. Final angiography showed good angiographic results (below, middle panel). The patient was prescribed aspirin and clopidogrel for six months. Six month follow up angiography (below, right panel) and intravascular ultrasound (upper right panel) showed no evidence of restenosis. Therefore, our case illustrates that the use of sirolimus eluting stents can be effective in the most complex lesion subset—distal left main ISR involving bifurcation.