Coronary stent disease: When will enough be enough?

Abstract

CLINICAL SUMMARY A 60-year-old man was transferred to the Sir Charles Gairdner Hospital with unstable angina. His comorbidities were obesity (body mass index 33.6 kg/m), hypertension, type II diabetes mellitus requiring insulin, hypercholesterolemia, and chronic renal failure (creatinine 150 mmol/L) due to diabetic nephropathy. The patient was an ex-smoker. Left ventricular ejection fraction was 45% with hypokinesis of the inferolateral wall. He had severely diseased left anterior descending (LAD) and left circumflex (LCx) coronary arteries with multiple in-stent stenoses (Figure 1) and a small nondominant right coronary artery. The patient had been previously managed elsewhere. In March of 2002, he was admitted with unstable angina and underwent percutaneous transluminal coronary angioplasty (PTCA) of the obtuse marginal (OM) branch. During angioplasty, the OM branch was dissected. A 2.5-mm Tsunami stent (Terumo Corporation, Tokyo, Japan) and a 2.5-mm Pixel stent (Guidant, Santa Clara, Calif) were placed to overlap the area of dissection. In October of 2002, unstable angina and in-stent stenosis of the OM developed, which were managed by PTCA alone. In May of 2003, unstable angina recurred. The patient underwent repeat PTCA to the LAD and LCx arteries, during which 3 Cypher stents (Cordis Corporation, Warren, NJ) were placed in the proximal LAD occluding the second diagonal branch and 4 Zeta stents (Abbott Laboratories, Abbott Park, Ill) were placed in the LCx. In January of 2007, the patient presented with unstable angina, inferolateral myocardial infarction, and pulmonary edema. The in-stent stenosis in the distal LCx was demonstrated, and the flow was restored with 4 Cypher stents. In March of 2007, he presented again with a prolonged episode of angina and inferolateral infarction and was found to have