Case 18: In-stent restenosis treated with RA
Case Presentation
A 58-year-old male presented with CCS class III chest pain to our hospital. He had a history of hypertension, diabetes mellitus, hyperlipidemia, and multiple PCIs. Most recently, a year ago, DESs were implanted in the proximal LAD (4.5 x 20mm) and mid LAD (4.0 x 48mm). Coronary angiography showed 80% in-stent restenosis in the proximal and mid LAD. Further assessment with IVUS showed concentric and eccentric neointimal hyperplasia, stent underexpansion and two stent layers in the proximal LAD. The MLA of the lesion was 2.9mm².
IVUS pre-treatment
Based on IVUS findings, we performed lesion modification with 1.75mm rotational atherectomy (RA) and then dilated with 4.5mm non-compliant (NC) balloon in the proximal LAD and 3.25mm NC balloon in the mid LAD. After ballooning, repeat IVUS showed significant increase in lumen area in the proximal and mid LAD with post procedural MLA 6.2mm².
IVUS post-treatment
In this case, IVUS helped classify mechanism of ISR (neointimal hyperplasia and stent underexpansion in the presence of two stent layers) and determine the optimal treatment strategy. Based on imaging, the lesion was treated with RA and NC balloon, and additional vascular brachytherapy (VBT) treatment was planned.
