A patient presented with recurrent in-stent restenosis of the circumflex and the mid and distal LAD. He had known ischemic cardiomyopathy with ejection fraction of 30-35% and a known CTO of the right coronary artery. Hemodynamic support was initiated using an Impella CP device. The Impella sheath was then punctured and a 7 French 45 cm long Pinnacle Destination sheath inserted, through which the PCI was performed.
The circumflex ISR lesion was nearly occlusive but was successfully crossed with a Caravel microcatheter and a Sion black guidewire. Despite multiple high-pressure balloon inflations the stent remained under-expanded as confirmed by IVUS. Shockwave lithoplasty was done with a 3.5x40 mm peripheral balloon that expanded the lesion, followed by brachytherapy of the proximal circumflex (the radioactive seeds could not be delivered to the distal circumflex due to tortuosity).
The LAD was subsequently also treated with Shockwave lithoplasty and brachytherapy and the first diagonal branch stented using the TAP (T and Protrusion) technique with an excellent final result.
