Fateh Ali Tipoo Sultan, Khawar Kazmi, Sajid Dhakam, Ataur Rehman Quraishi.
Late in-stent restenosis in a patient with Drug-eluting Stent.
J Coll Physicians Surg Pak Jan ;15(10):648-9.

A 74 years old diabetic, hypertensive and dyslipidemic gentleman first presented in August 2002 with Canadian cardiac society (CCS) II angina and a positive stress test. Coronary angiography revealed 80% lesion in mid Left Anterior Descending artery (LAD), 80% lesion in distal third of Left Circumflex (LCX) which was a small vessel, and 100% proximal occlusion of large dominant Right Coronary Artery (RCA) which was filling through left sided collaterals. Left ventricular angiogram was normal. After consent from the patient, PCI was done on September 4, 2002. Mid LAD lesion was predilated with World pass balloon (2.5x20) at 6 atmosphere(atm) followed by implantation of 3.0~33 Rapamycin eluting stent at 10 atm. Complete resolution of the lesion was achieved and no postdilatation was done. PCI of the completely occluded RCA was also attempted but the wire could not be crossed through the lesion. Aspirin for life long and clopidogrel for six months was advised. Patient remained well after the procedure with complete resolution of symptoms. No functional study was done as patient was asymptomatic on functional class I activities. In November 2003, the patient was hospitalized with acute coronary syndrome (chest pain and ECG changes in anterior chest leads). His anti-anginal medications were optimized, but he continued to have CCS III / IV angina. Coronary angiography was performed in December, 2003, which revealed 2 sites of focal 90% in-stent restenosis, which were treated with balloon angioplasty using a cutting balloon. A 60% lesion just distal to the stent was treated with stent placement achieving TIMI III flow and no residual lesion.

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