Stentless percutaneous coronary intervention with directional coronary atherectomy and drug-coated balloon angioplasty in worsening angina patients with metal allergies

Abstract

Metal allergy is a concern in percutaneous coronary intervention (PCI) with stent implantation because of its potential association with poor cardiovascular outcomes, such as stent thrombosis and recurrent in-stent restenosis requiring revascularization. Although stentless PCI with drug-coated balloon (DCB) angioplasty is theoretically useful for patients with metal allergies, DCB angioplasty alone for huge plaques in large vessels may yield inadequate luminal enlargement and coronary deep dissection, leading to insufficient results. Directional coronary atherectomy (DCA) is effective to reduce plaque volume. However, the efficacy of DCA followed by DCB (DCA/DCB) angioplasty in patients with metal allergies has never been described. We present two cases wherein stentless PCI with DCA/DCB angioplasty was an alternative revascularization strategy for patients with metal allergy and concomitant worsening angina pectoris involving proximal left anterior descending artery stenoses. Preoperative evaluation using coronary computed tomography angiography in Case 1 and intravascular ultrasound in Case 2 was useful to determine the possible use of the DCA/DCB procedure for huge plaques in large vessels.

Learning objective: Revascularization for patients with metal allergy with worsening angina pectoris due to stenoses of the proximal main arteries is often challenging because of the necessity to avoid stent implantation. As stentless percutaneous coronary intervention (PCI) is theoretically useful in such settings, PCI with directional coronary atherectomy (DCA)/drug-coated balloon angioplasty can be one of the treatable strategies. Preoperative evaluation of plaque morphology for the suitability of DCA procedure is important.

Keywords: CABG, coronary artery bypass grafting; CAD, coronary artery disease; CAG, coronary angiography; CCS, Canadian Cardiovascular Society; CCTA, coronary computed tomography angiography; DCA, directional coronary atherectomy; DCB, drug-coated balloon; Directional coronary atherectomy; Drug-coated balloon angioplasty; ISR, in-stent restenosis; LAD, left anterior descending artery; Metal allergy; OM, obtuse marginal branch; PCB, paclitaxel-coated balloon; PCI, percutaneous coronary intervention; Percutaneous coronary intervention; RCA, right coronary artery; Stentless; TIMI, thrombolysis in myocardial infarction.

Fig. 1

Multimodal images in Case 1 (A–C) Coronary angiography (CAG) showing multivessel disease (dotted lines). (D–F) Coronary computed tomography angiography showing non-calcified plaque in the left anterior descending artery (LAD). Massive plaque in the distal left main trunk extending from the proximal LAD (arrowheads). (G–H) Comparison of each lesion on intravascular ultrasound (G) before and (H) after directional coronary atherectomy (DCA). Resected region by DCA (arrowheads). (I–K) CAG performed at 8 months later, showing no restenosis. An asterisk indicates high lateral branch.

Fig. 2

Preoperative examination (A, B) Exercise-stress cardiac scintigraphy showing significant myocardial ischemia in the anterior part and apex of the left ventricle (yellow arrows) with total perfusion defect of 19 %. (C) Patch tests for various metal alloy show mercury, zinc, and nickel allergies (circles).

Fig. 3

Multimodal images in Case 2. (A–C) Coronary angiography (CAG) showing the proximal left anterior descending artery stenosis. (D, E) Comparison of each lesion on intravascular ultrasound (D) before and (E) after directional coronary atherectomy (DCA). Resected region by DCA (arrowheads). (F–H) CAG performed at 9 months later, showing no restenosis.