Case presentation

A 53-year-old man, with hypertension, dyslipidemia, and a history of multiple prior percutaneous coronary interventions involving the proximal left anterior descending artery, presented to his physician with a 3-month history of progressively worsening exertional chest pressure and left arm pain, similar to his previous episodes of angina.

Two years earlier, he first developed classic effort angina. An abnormal stress test led to a coronary angiogram, which revealed a severe stenosis in the proximal segment of the left anterior descending coronary artery (Figure 1-1 and Video 1-1). This was treated with a 3.0 mm diameter by 23 mm long sirolimus-eluting stent, with an excellent angiographic result (Figure 1-2 and Video 1-2). His angina completely resolved; however, 10 months after the procedure, he developed recurrent effort angina. Coronary angiography confirmed severe, focal, in-stent restenosis within the proximal edge of the drug-eluting stent (Figure 1-3). Balloon angioplasty using a 3.0 mm noncompliant balloon dilated to 16 atmospheres improved the angiographic appearance (Figure 1-4 and Video 1-3) and resolved the patient’s symptoms. However, 6 months later (and 9 months before his current presentation) the development of recurrent angina prompted another angiogram. A second recurrence of in-stent restenosis within the proximal left anterior descending artery stent (Figure 1-5 and Video 1-4) was treated with a 3.0 mm diameter by 30 mm long zotarolimus-eluting stent, again with good angiographic result (Figure 1-6A). Intravascular ultrasound performed after this procedure demonstrated excellent stent apposition throughout the stented segment (Figure 1-6B). He remained symptom-free for 6 months until this presentation.

FIGURE 1-1 This is a representative left coronary angiogram in a left anterior oblique projection with caudal angulation, demonstrating the severely stenosed segment of the proximal left anterior descending artery prior to intervention (arrow).

FIGURE 1-2 This angiogram shows the final angiographic result after insertion of a 3.0 mm diameter by 23 mm long sirolimus-eluting stent.

FIGURE 1-3 This angiogram was obtained after the patient developed recurrent angina, and reveals severe focal in-stent restenosis of the proximal edge of the sirolimus-eluting stent within the proximal left anterior descending artery (arrow) (right anterior oblique projection with cranial angulation).

FIGURE 1-4 This is the result after balloon angioplasty of the restenotic lesion in the proximal left anterior descending artery shown in Figure 1-3.

FIGURE 1-5 This figure depicts the second recurrence of in-stent restenosis at the proximal edge of the sirolimus-eluting stent within the proximal left anterior descending artery (arrow).

FIGURE 1-6 The second episode of restenosis was treated with a zotarolimus-eluting stent, and the angiographic result (A) and representative intravascular ultrasound image (B) after receiving a 3 mm diameter by 30 mm long zotarolimus-eluting stent.

Cardiac catheterization