Watanabe Nobuhiro, Yamamoto Hiroyuki, Kawahara Kunimitsu, Takaya Tomofumi
Division of Cardiovascular Medicine, Hyogo Prefectural Harima-Himeji General Medical Center, 3-264 Kamiya-cho, 670-8560 Himeji, Japan.
Division of Pathology for Regional Communication, Kobe University Graduate School of Medicine, Kobe, Japan.
Eur Heart J Case Rep. 2023 Dec 11;8(1):ytad626. doi: 10.1093/ehjcr/ytad626. eCollection 2024 Jan.
Neoatherosclerosis, a prominent contributor to in-stent restenosis (ISR), persists as a formidable challenge during percutaneous coronary intervention. Excimer laser coronary atherectomy (ELCA) and embolic protection devices may help reduce coronary flow disturbance from procedure-related distal embolization.
A 71-year-old man experienced in-stent neoatherosclerosis rupture-related non-ST segment elevation myocardial infarction. Multidisciplinary intracoronary imaging, including intravascular ultrasound and optical coherence tomography (OCT), suggested that the ISR was caused by a neoatherosclerosis rupture that can potentially lead to distal embolization. Excimer laser coronary atherectomy (fluence, 45 mJ/mm and frequency, 25 pulse/s) using a 1.7 mm concentric catheter was performed with distal protection using Filtrap (Nipro Corporation, Tokyo, Japan), which significantly reduced the volume of the neoatherosclerosis. However, subsequent ELCA on the highest setting (fluence, 60 mJ/mm and frequency, 40 pulse/s) led to a filter no-reflow phenomenon, although OCT revealed a further effective vaporization of the neoatherosclerosis and an apparent reduction of soft tissue compatible with the thrombus. After removing the embolic protection device, drug-coated balloon angioplasty provided optimal results without coronary flow disturbance.
Excimer laser coronary atherectomy reduces soft plaque and thrombus burden, which can reduce the occurrence of distal embolization in select cases. In the case of this patient, procedure-related distal embolization may have been induced by the heightened photomechanical effects resulting from the use of the highest setting in ELCA under increased intracoronary arterial pressure caused by continuous saline injection during ELCA. Concomitant distal protection during ELCA may be more feasible for preventing coronary flow disturbance in patients with a large amount of neoatherosclerosis.
新生动脉粥样硬化是支架内再狭窄（ISR）的一个重要促成因素，在经皮冠状动脉介入治疗期间仍然是一个巨大挑战。准分子激光冠状动脉斑块旋切术（ELCA）和栓子保护装置可能有助于减少与手术相关的远端栓塞引起的冠状动脉血流紊乱。
一名71岁男性经历了支架内新生动脉粥样硬化破裂相关的非ST段抬高型心肌梗死。包括血管内超声和光学相干断层扫描（OCT）在内的多学科冠状动脉内成像表明，ISR是由新生动脉粥样硬化破裂引起的，这可能会导致远端栓塞。使用1.7毫米同心导管进行准分子激光冠状动脉斑块旋切术（能量密度，45 mJ/mm；频率，25脉冲/秒），并使用Filtrap（日本东京日普乐株式会社）进行远端保护，这显著减少了新生动脉粥样硬化的体积。然而，随后在最高设置（能量密度，60 mJ/mm；频率，40脉冲/秒）下进行的ELCA导致了滤器无复流现象，尽管OCT显示新生动脉粥样硬化进一步有效汽化，与血栓相容的软组织明显减少。移除栓子保护装置后，药物涂层球囊血管成形术取得了最佳效果，且无冠状动脉血流紊乱。
准分子激光冠状动脉斑块旋切术可减轻软斑块和血栓负荷，在某些情况下可减少远端栓塞的发生。在该患者的病例中，手术相关的远端栓塞可能是由于在ELCA期间持续注射生理盐水导致冠状动脉内压力升高的情况下，使用ELCA最高设置所产生的增强光机械效应引起的。在ELCA期间同时进行远端保护对于预防大量新生动脉粥样硬化患者的冠状动脉血流紊乱可能更可行。
