Rotational atherectomy in restenotic lesions at the distal saphenous vein graft anastomosis

Successful angioplasty of saphenous venous graft in-stent restenosis using rotational atherectomy

An 81-year-old, functionally independent woman with a history of bypass surgery and a previous vein graft intervention presented to us with significant angina refractory to medical management. An urgent angiogram revealed severe in-stent restenosis (ISR) in the proximal stent of the right coronary artery graft. At the same time, multiple trials to predilate the tight ISR using various-sized non-compliant and cutting balloons were unsuccessful. During the second attempt the next day, rotational atherectomy was used for plaque modification as the lesion appeared fibrocalcific angiographically. A good imaging result was obtained after final dilatation with a drug-eluting balloon, and the patient also achieved immediate angina relief. Even though rotational atherectomy is contraindicated in vein graft interventions, it can be successfully used in selected cases when routine angioplasty techniques fail.

Rotational atherectomy in the distal left anterior descending coronary artery through an internal mammary artery graft

We report the case of a 53-year-old white man who began complaining of dyspnoea and angina 19 months after coronary artery bypass graft surgery. Coronary angiography revealed the presence of a long and critical stenosis in the native left anterior descending coronary artery, shortly after distal anastomosis of the left internal mammary artery. After failed predilatations with standard or cutting balloons, we successfully used the rotablator system, which allowed us to implant a bare-metal stent in the native left anterior descending coronary artery. However, stent deployment caused long linear graft dissection, which was reduced by drug-eluting stent implantation in the proximal and distal segments of the left internal mammary artery.