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ª 2 0 1 5 B Y T H E AM E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N DA T I O N I S S N 1 9 3 6 - 8 7 9 8 / $ 3 6 . 0 0

P U B L I S H E D B Y E L S E V I E R I N C . h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . j c i n . 2 0 1 5 . 0 2 . 0 1 8

IMAGES IN INTERVENTION

Excimer Laser Angioplasty–FacilitatedFracturing of Napkin-Ring Peri-StentCalcium in a Chronically Underexpanded Stent

Documentation by Optical Coherence Tomography

Da Yin, MD,*y Akiko Maehara, MD,*y Stephen Mezzafonte, MD,z Jeffrey W. Moses, MD,*y Gary S. Mintz, MD,*Richard A. Shlofmitz, MDz

A 79-year-old man underwent stent implan-tation into a severely calcified proximalleft anterior descending coronary lesion

(Figure 1) in December 2012 followed by restenting inMarch 2014 to treat in-stent restenosis (Figure 2),both without full balloon expansion. Optical coher-ence tomography (OCT) documented thick, peri-stent napkin-ring calcium. He was admitted forrecurrent unstable angina in April 2014. After initialtreatment with excimer laser coronary angioplasty(ELCA; 1.4 mm, Spectranetics Corporation, ColoradoSprings, Colorado) using saline injection, fluence of60 mJ/mm2, and frequency of 80 Hz, a balloon wasfully expanded. OCT showed fracturing of peri-stent

From the *Cardiovascular Research Foundation, New York, New York; yColumand zSt. Francis Hospital, Roslyn, New York. Dr. Maehara has received gran

Boston Scientific and ACIST Medical Systems; and has received speaker’s fee

Boston Scientific. Dr. Mintz has received grant support and is a consulta

Dr. Shlofmitz is on the speakers bureaus of CSI, Janssen Pharmaceuticals, a

reported that they have no relationships relevant to the contents of this pap

Manuscript received February 19, 2015; accepted February 26, 2015.

calcium and good stent expansion (Figure 3). Thisapproach has been reported in the ELLEMENT(Excimer Laser LEsion Modification to Expand Non-dilatable sTents) registry (1); in the current case, weused OCT to document the mechanism behind thisapproach.

ACKNOWLEDGMENTS The authors thank FernandoA. Sosa, MS, from St. Jude Medical for his assistancein image collection.

REPRINT REQUESTS AND CORRESPONDENCE: Dr.Akiko Maehara, Cardiovascular Research Foundation,111 East 59th Street, 12th Floor, New York, NewYork 10022. E-mail: amaehara@crf.org.

bia University Medical Center, New York, New York;

t support from Boston Scientific; is a consultant for

s from St. Jude Medical. Dr. Moses is a consultant for

nt for Boston Scientific and Volcano Corporation.

nd St. Jude Medical. Drs. Yin and Mezzafonte have

er to disclose.

FIGURE 1 Coronary Angiogram, December 2012

Calcium appeared as radio-opaque bands on both sides of the lumen (A, A’) and circumferential (B, B’). A stent (2.75 � 22 mm) was post-dilated

by a noncompliant balloon (3.0 � 9 mm, 22 atm) with a final 28% diameter stenosis (DS). Boxed areas in A and B are shown magnified in A0 and

B0, respectively.

FIGURE 2 Coronary Angiogram and OCT, March 2014

An additional stent (3.5 � 12 mm) was implanted and post-dilated by a noncompliant balloon (4.0 � 9 mm, 26 atm) with a 39% final diameter

stenosis (DS). Optical coherence tomography (OCT) showed diffuse circumferential calcium (white arrows) behind an underexpanded stent

(white asterisks) with a pre-intervention minimum stent area of 2.75 mm2 and only mild intimal hyperplasia.

Yin et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 8 , N O . 8 , 2 0 1 5

ELCA Fracturing of Napkin-Ring Peri-Stent Calcium J U L Y 2 0 1 5 : e 1 3 7 – 9

e138

FIGURE 3 Coronary Angiogram and OCT, April 2014

Matched OCT slices and longitudinal reconstruction showed a pre-excimer laser coronary angioplasty (ELCA) MSA of 2.26 mm2, no change

post-ELCA (white arrow), but fracturing of the thinnest part of the calcium after balloon post-dilation with a noncompliant balloon

(3.5 � 9 mm, 22 atm) resulting in good stent expansion (MSA ¼ 6.34 mm2) and a final DS of 10%. Abbreviations as in Figure 2.

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 8 , N O . 8 , 2 0 1 5 Yin et al.J U L Y 2 0 1 5 : e 1 3 7 – 9 ELCA Fracturing of Napkin-Ring Peri-Stent Calcium

e139

RE F E RENCE

1. Latib A, Takagi K, Chizzola G, et al. Excimerlaser lesion modification to expand non-dilatablestents: the ELLEMENT registry. CardiovascRevasc Med 2014;15:8–12.

KEY WORDS calcium, excimer lasercoronary angioplasty, optical coherencetomography