PMC3056211_01
Angiography of the left circumflex artery showing chronic total occlusion in the mid segment (a), postdilatation of the overlap stent segment with a noncompliant balloon (b), and final result showing stent underexpansion in the overlap segment (c). Complete acute occlusion of the left circumflex artery (arrow) due to subacute stent thrombosis ((d) caudal view and (e) cranial view), and the final TIMI-1 flow after failed thrombectomy and progressive dilations of the overlapped segment with oversized noncompliant balloons (f).
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Coronary angiography showed multivessel calcified disease with a long calcified lesion in the proximal mid-left descending coronary artery (LAD), chronic total occlusion (CTO) of the mid circumflex artery (LCX) (Figure 1(a)), and a severe lesion in the proximal right coronary artery segment (RCA). TAXUS Liberte 2.5 x 32 mm (Boston Scientific Corp., Natick, Massachusetts) were deployed in the distal and mid segments, respectively. The angiography showed focal underexpansion in the overlap segment, so, postdilatation using Quantum 2.5 x 12 mm and 2.75 x 12 mm (Figure 1(b), arrow; Boston Scientific Corp, Natick, Massachusetts) noncompliant balloons was performed with poor final angiographic result due to final underexpansion (Figure 1(c), arrow). Two days later, PCI was performed in the LAD and RCA using rotational atherectomy and two DES with good angiographic result.  Urgent angiography showed in-stent thrombosis of the proximal LCX (Figure 1(d) caudal view and Figure 1(e) cranial view), while both stents in RCA and LAD were patent. TIMI 1; Figure 1(f)). The patient was discharged 72 hours later without in-hospital complications and preserved LVEF on echocardiogram, with posterolateral hypokinesia.
Optical coherence tomographic (OCT) images during pullback from distal (a) to proximal (c) segments. OCT showed severe focal stent underexpansion (b) localized in the overlapping segment, where two struts layers are visible (arrows) and fragments of in-stent remnant thrombus (arrowheads) after balloon dilation.
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Then, an optical coherence tomography (OCT) probe (ImageWire, Lightlab Imaging, Westford, Massachusetts) was directly advanced with gentle torque to the distal LCX, and images were obtained using nonocclusive technique, with 2 mm/sec of motorized pullback during automated injection of dye (Iodixanol) through the guiding catheter at 2 mm/sec (Figure 2).