Metal allergy is a concern in percutaneous coronary intervention (PCI) with stent implantation because of its potential association with poor cardiovascular outcomes, such as stent thrombosis and recurrent in-stent restenosis
A new report published in the Journal of Cardiology Cases showed that for patients with coronary artery disease (CAD) and metal allergies, stentless percutaneous coronary intervention (PCI) using directional coronary atherectomy (DCA)/drug-coated balloon (DCB) angioplasty under preoperative coronary imaging examination of plaque morphology may be an appropriate method.

Due to its possible link to adverse cardiovascular outcomes such stent thrombosis and recurring in-stent restenosis necessitating revascularization, metal allergy is a concern in percutaneous coronary intervention with stent implantation. Theoretically, patients with metal allergies may benefit from stentless PCI with drug-coated balloon angioplasty; however, DCB angioplasty alone for massive plaques in large vessels may result in insufficient luminal enlargement and coronary deep dissection, with consequently insufficient results. For reducing plaque volume, directional coronary atherectomy is useful.
In this study, researchers discuss two cases in which proximal left anterior descending artery stenosis were involved, and stentless PCI with DCA/DCB angioplasty served as a different revascularization technique for patients with metal allergies and concurrently worsening angina pectoris.
Case 1:
Through a patch test, a 66-year-old man with a history of hypertension, type 2 diabetes, and dyslipidemia had been identified as having definite nickel allergy. The Canadian Cardiovascular Society (CCS) classified the patient's exertional angina pectoris as class 3 when they first saw them. Prior to PCI, coronary computed tomography angiography (CCTA) revealed that the proximal left anterior descending artery (LAD) lesion was composed of a massive, non-calcified plaque in a big artery with a diameter of at least 3.5 millimeters, indicating that it was a candidate for stentless PCI with DCA/DCB angioplasty. After considerable discussion with the cardiac team and consideration of the patient's growing symptoms and desire, we chose to conduct stentless PCI with DCA/DCB angioplasty.
Following a successful PCI with DCA/DCB angioplasty, the proximal OM lesion was subsequently treated with balloon angioplasty utilizing a 2.75/10-mm cutting balloon and 2.75/25-mm PCB, which produced optimum luminal expansion and TIMI grade 3 thrombolysis. After stentless PCI, the patient's clinical history was unremarkable, and she was released two days later. After 8 months, Coronary angiography (CAG) revealed ideal outcomes without restenosis, and the patient went 33 months without any overt angina symptoms.
Case 2:
Angina pectoris due to exercise struck a 70-year-old lady with a history of hypertension and dyslipidemia (CCS classification 3). Exercise-stress cardiac scintigraphy revealed severe myocardial ischemia and a 19% total left ventricular perfusion deficit. The proximal LAD stenosis was seen on CAG. An further IVUS test for preoperatively assessing plaque morphology revealed a soft plaque with minor superficial calcification, which was expectedly acceptable for DCA. This was because of the patient's strong willingness to have stentless PCI and her unwillingness to undergo CABG. Based on these results, the cardiac team decided to use DCA/DCB angioplasty together with stentless PCI as a revascularization method.
On IVUS images, DCA was carried out utilizing AtherocutTM L in six sessions with a total of 30 cuts. This allowed for the ideal decrease in plaque volume from preoperatively 78% to postoperatively 45%. A 3.5/13-mm scoring balloon and a 4.0/20-mm PCB were used for the balloon angioplasty procedure. The final CAG then displayed the best results with TIMI grade 3 utilizing a 2.25/10-mm cutting balloon and a 2.5/30-mm PCB for the diagonal branch. After stentless PCI, the patient's clinical course went without incident, and 9 months later, a CAG revealed no restenosis. For 30 months, the patient did not appear to have angina symptoms.
Reference:
Yamamoto, H., Fujii, M., Tsukiyama, Y., Kawai, H., & Takaya, T. (2023). Stentless percutaneous coronary intervention with directional coronary atherectomy and drug-coated balloon angioplasty in worsening angina patients with metal allergies. In Journal of Cardiology Cases (Vol. 27, Issue 1, pp. 32–35). Elsevier BV. https://doi.org/10.1016/j.jccase.2022.09.014