LAUSR

A 69-year-old woman with angina was referred for percutaneous coronary intervention (PCI). A new-generation drug-eluting stent (DES) with a bioresorbable polymer was implanted at the left anterior descending (LAD) artery because of a severe acute lesion (Fig. 1a, b). As diagonal branch flow was impaired, recrossing was attempted. However, the wire produced a diagonal branch dissection and conservative management was decided. Optical coherence tomography (OCT) showed stent underexpansion and a proximal stent edge dissection (Fig. 1c), so post-dilatation was successfully performed, but conservative management of the stent edge dissection was conducted. One year later, the patient was admitted for progressive angina. Coronary angiography showed contrast retention at mid-LAD (Fig. 1d) and OCT confirmed an LAD aneurysm with acquired malapposition of the previous stent (Fig. 1e, Online Resource 1). Due to the risk of stent thrombosis, and assuming the high probability of diagonal occlusion, we decided to exclude the LAD aneurysm with a Papyrus covered stent (PCS) [Biotronik]. A wire was placed at the diagonal branch as a marker and, subsequently, two overlapped PCS were implanted at LAD sealing the aneurysm but occluding the diagonal. With a 90o-angled-tip Supercross microcatheter (Teleflex) and a Hornet-14 wire (Boston Scientific), the PCS was fenestrated and subsequently crossed with a Pilot 200 wire (Abbott) [“stick and swap” technique]. After dilatation with a low-profile balloon, flow towards the diagonal branch was recovered (Fig. 1f, g). We decided not to stent the diagonal as it was diffusely diseased. As OCT showed proximal stent edge dissection again, another overlapped DES was implanted with an excellent result (Online Resources 2–3). Intracoronary imaging techniques can detect abnormalities following stent implantation which are associated with poor outcomes [1]. OCT-guided PCI allows a better stent optimization and helps to detect significant stent edge dissections. Although it is recommended to treat large distal stent edge dissections, there is no consensus on what to do with proximal ones [2]. In this case, flow towards the proximal stent edge dissection might have caused the acquired coronary aneurysm. Moreover, this case shows how PCS implantation is a feasible option as a bailout in this scenario and that it can also be fenestrated to maintain flow to side branches.