Doctor & Patient Education Cardiac Specialist Centre
Intervention
4. Absorb in ISR
Implantation of Absorb in Chronic Total Occlusion
of In-Stent-Restenosis

The following 2 cases were presented in Asia PCR(SingLive) on 23rd January 2015 by
Dr. Tan Chong Hiok

Bio-Absorbable stent

  • Stents have been used to keep narrowed or blocked arteries opened for the last 20 years
  • They have always been made of metals which means that they will always remain in the artery implanted forever
  • Recently new materials have been used for these scaffolds which will 'dissolve' over a 2 year period
  • That means that at the end of 2 years, no traces of the scaffold remains
  • Time has been ‘turned back’ and the artery is back to its original un-diseased state

Abbott and Elixir

  • Presently there are 2 bio-absorbable available in Singapore
  • The ‘Absorb’ by Abbortt and 'DESolve' by Elixir
  • Both are made of Poly-Lactic acid
  • They have generally been used in simple cases
  • The following 2 cases are complex intervention utilising the Absorb stent

CASE 1 - BMS ISR

  • 68 Yr gentleman
  • 2008 Bare metal stent used to treat the original RCA CTO
  • In 2010 there was in-stent-restenosis which was treated with drug eluting balloon
  • In 2014 he presented again with chronic total occlusion of the repeated in-stent-restenosis
  • He was suffering from angina

Crossing the CTO

  • Using a 2.5 x 15mm OTW balloon as anchor/support
  • Fielder XT-A crossed the CTO segment

Sequential balloon dilatation

  • Dilatation of the occluded vessel was performed with sequentially larger balloons
  • Starting with Sprinter Legend 1.25 x 12 at 14 atm
  • Then Sprinter Legend 2.0 x 12 at 14 atm
  • Finally Kaneka Fortis 3.25 x 18 up to 22 atm
  • However, the mid RCA could not be adequately dilated

Let’s try cutting balloon

  • Using Flextome 3.5 x 10 inflated up to 14 atm
  • Full expansion still could not be achieved


Still looking hazy

  • After repeated cutting balloon dilatations
  • There is still a little haziness at the mid RCA

Let’s try Absorb

  • Placement of Absorb 3.5 x 28mm BVS

After the Absorb the mid RCA looked better. However, the ostium is not well expanded



Final angiogram

  • After placing another Absorb 3.5 x 18 in the ostium RCA
  • Post dilated with 4.0 x 15 mm NC balloon up to 17 atm
  • RPL stented with Xience 2.5 x 38
  • The artery looked fully revascularised

CASE 2 - DES ISR

  • 2nd case is again in RCA
  • In 2012 the RCA was treated with DES from pRCA to RPDA
  • Drug-eluting balloon was used to treat the RPL

CTO was Crossed with Gaia 2nd on Corsair

  • After 3.5 NC along RCA
  • Kissing balloon 2.5 into the PRL and PDA
  • The RPL after the PDA still looking very stenosed


Anchoring balloon placed in PDA

  • Squeezed an Absorb 2.5 x 18 into RPL
  • Re-crossed into PDA finished with kissing balloon

 

  • The RPL now looks more respectable
  • But the prox-mid RCA still not ideal

Another Absorb in proximal RCA

  • Absorb 3.5 x 28 placed in pRCA up to 14atm

LAO final angiogarm

AP cranial

Options for treatment in these cases
  • Leave them as they are after NC and cutting balloon
  • Treat with Drug eluting balloon – But the post dilatation result was not idea
  • DES – 2-3 layers of permanent metal
  • BVS – Hopefully it dissolves leaving single layer of Metal and a big lumen
  • Acute result looks acceptable
  • Long term result presently unknown
Consultation
Know Your Cardiologists

I feel breathless when walking.

I feel a tightness over my chest.

Do I need to take my medicine for my blood pressure?

Do I need to take my medicine for my cholesterol?

Do I really need stents for my artery?

Do I really need to have a bypass operation?

When should I go for health screening?

I have heart problem, can I take Viagra?

I have heart problem, should I exercise?

Heart Disease
Learn about your heart Conditions

You may need an ultra sound scan of your heart to assess its function.

You may need a treadmill stress test.

You may need closer monitoring.

You may need a more thorough risk assessment and life style change.

You may only need to take your medicine.

You may get away with just stenting.

This generally should start at 40 years old.

Yes, but there are certain strict conditions to fulfill.

Yes, but you will need to find out the appropriate intensity.