IJCS | Volume 31, Nº4, July / August 2018

DOI: 10.5935/2359-4802.20180040 454 CASE REPORT International Journal of Cardiovascular Sciences. 2018;31(4)454-456 Mailing Address: Marcos Garcia-Guimaraes Calle Tutor 68 Bajo interior Izquierda. Postal Code: 28008, Madrid - Spain. E-mail: marcos.garcia.guimaraes@gmail.com , guima85@hotmail.com Sirolimus-Eluting Balloon Treatment of Distal Internal Mammary Artery Anastomosis: Optical Coherence Tomography Findings Marcos Garcia-Guimarães, RamónMaruri-Sanchez, Javier Cuesta, Fernando Rivero, Teresa Bastante, Fernando Alfonso Hospital Universitario de La Princesa, Madrid - Spain Manuscript received March 25, 2017, revised manuscript October 23, 2017, accepted February 22, 2018. Angioplasty, Balloon, Coronary /methods; Coronary Artery Disease / diagnosis; Drug-Eluting Stents; Treatment Outcome; Sirolimus. Keywords Drug-eluting balloons (DEB) represent an interesting alternative to current generation drug-eluting stents (DES) in selected anatomic scenarios, such as in-stent restenosis, small-vessel disease and bifurcation lesions, where the systematic implantation of DES may result less appealing. 1,2 In particular, lesions located at the distal anastomosis of a bypass graft (an artificially created bifurcation) constitute a unique anatomic setting, where DEB may overcome some inherent limitations of DES resulting from the implantation of a metallic platform throughout the bypass graft into and across the native distal vessel. Herein we present, to the best of our knowledge, the first report of the treatment of a lesion located at the distal anastomosis of a left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) with a novel sirolimus-DEB. Interestingly, optical coherence tomography (OCT) findings proved to be of major value to guide the procedure. An 83-year-old man with previous history of hypertension, hyperlipidemia and ex-smoker was admitted with acute coronary syndrome. Coronary angiography revealed 3-vessel coronary artery disease, with a total occlusion at the mid-segment of the LAD and additional significant lesions at the obtuse marginal branch (OM) and mid-segment of the right coronary artery (RCA). After discussion in a Heart-Teammeeting, a decision for a hybrid revascularization strategy was made. Off-pump coronary artery bypass grafting (CABG) was performed with a LIMA anastomosed to the distal LAD and a saphenous vein graft from LIMA to OM. The postoperative period was uneventful. A week later, the scheduled percutaneous coronary intervention was successfully performed with a DES implanted at the mid RCA. However, during the procedure a revision of the bypass grafts revealed the presence of a significant lesion at the distal anastomosis of LIMA to LAD (Figure 1A). Due to a suspicious of pseudo-stenosis secondary to edema or spasm related to the recent surgery, it was decided to reevaluate this lesion later on. The scheduled control angiogram at 1 month revealed the persistence of the same image of a severe lesion at the distal anastomosis of the LIMA. The lesion appearance remained unaltered after repeated boluses of nitroglycerin. To gain further diagnostic insights, OCT imaging was performed. This imaging technique confirmed the presence of a critical stenosis with a severely reduced lumen (minimal lumen area 1.0 mm 2 ) (Figure 2A). After lesion predilation with a 2.0 mm semi-compliant balloon, a 2.5/15 mm sirolimus-DEB (MagicTouch, Concept Medical Inc, Surat, India) was used to treat the distal anastomosis (Figure 1B). A good immediate result was confirmed both by angiography (Figure 1C) and OCT (Figures 2B and 2C). The patient was discharged the day after and remains completely asymptomatic at the 9-month follow-up. The diagnosis of lesions located in the distal LIMA anastomosis may be very challenging. When these lesions are detected in the early postoperative period technical problems should be differentiated from reversible causes, such as edema or spasm. Notably, however, the value of OCT to get further diagnostic insights on these elusive lesions has not been previously reported. Our findings underscore the usefulness of this technique to disclose the underlying substrate and to assess lesion severity before intervention and to guide and optimize the results of interventions. Lesions