IMPLANTATION OF ABSORB IN CHRONIC TOTAL OCCLUSION
OF IN-STENT-RESTENOSIS
The following 2 cases were presented in Asia PCR(SingLive) on 23rd January 2015 by Dr. Tan Chong Hiok
Bio-Absorbable stent
- Stents have been used to keep narrowed or blocked arteries opened for the last 20 years
- They have always been made of metals which means that they will always remain in the artery implanted forever
- Recently new materials have been used for these scaffolds which will ‘dissolve’ over a 2 year period
- That means that at the end of 2 years, no traces of the scaffold remains
- Time has been ‘turned back’ and the artery is back to its original un-diseased state
Abbott and Elixir
- Presently there are 2 bio-absorbable available in Singapore
- The ‘Absorb’ by Abbortt and ‘DESolve’ by Elixir
- Both are made of Poly-Lactic acid
- They have generally been used in simple cases
- The following 2 cases are complex intervention utilising the Absorb stent
CASE 1 – BMS ISR
- 68 Yr gentleman
- 2008 Bare metal stent used to treat the original RCA CTO
- In 2010 there was in-stent-restenosis which was treated with drug eluting balloon
- In 2014 he presented again with chronic total occlusion of the repeated in-stent-restenosis
- He was suffering from angina
Crossing the CTO
- Using a 2.5 x 15mm OTW balloon as anchor/support
- Fielder XT-A crossed the CTO segment
Sequential balloon dilatation
- Dilatation of the occluded vessel was performed with sequentially larger balloons
- Starting with Sprinter Legend 1.25 x 12 at 14 atm
- Then Sprinter Legend 2.0 x 12 at 14 atm
- Finally Kaneka Fortis 3.25 x 18 up to 22 atm
- However, the mid RCA could not be adequately dilated
Let’s try cutting balloon
- Using Flextome 3.5 x 10 inflated up to 14 atm
- Full expansion still could not be achieved

Still looking hazy
- After repeated cutting balloon dilatations
- There is still a little haziness at the mid RCA
Let’s try Absorb
- Placement of Absorb 3.5 x 28mm BVS
After the Absorb the mid RCA looked better. However, the ostium is not well expanded

Final angiogram
- After placing another Absorb 3.5 x 18 in the ostium RCA
- Post dilated with 4.0 x 15 mm NC balloon up to 17 atm
- RPL stented with Xience 2.5 x 38
- The artery looked fully revascularised
CASE 2 – DES ISR
- 2nd case is again in RCA
- In 2012 the RCA was treated with DES from pRCA to RPDA
- Drug-eluting balloon was used to treat the RPL
CTO was Crossed with Gaia 2nd on Corsair
- After 3.5 NC along RCA
- Kissing balloon 2.5 into the PRL and PDA
- The RPL after the PDA still looking very stenosed

Anchoring balloon placed in PDA
- Squeezed an Absorb 2.5 x 18 into RPL
- Re-crossed into PDA finished with kissing balloon
- The RPL now looks more respectable
- But the prox-mid RCA still not ideal
Another Absorb in proximal RCA
- Absorb 3.5 x 28 placed in pRCA up to 14atm
LAO final angiogarm
AP cranial
Options for treatment in these cases
- Leave them as they are after NC and cutting balloon
- Treat with Drug eluting balloon – But the post dilatation result was not idea
- DES – 2-3 layers of permanent metal
- BVS – Hopefully it dissolves leaving single layer of Metal and a big lumen
- Acute result looks acceptable
- Long term result presently unknown