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In-Stent Restenosis with Jailed Side Branch

Operator: Joseph Sweeny, MD
Interventional Fellow: Rohit Malhotra, MD
A 67-year-old man with multiple prior MIs and PCIs presented with weeks-long worsening exertional dyspnea and occasional chest pain at rest relieved with nitroglycerine. Diagnostic catherization two months prior revealed D1 stenosis 70-80%, and patent intervention sites in the RCA and LCx. Recent SPECT MRI at off-site hospital showed reversible anterior and septal wall defect. Coronary angiography showed in-stent restenosis of mid LAD bifurcation lesion (Figure 1A, blue arrow) and a stent-jailed 90-95% occlusion of D1 ostium (Figure 1B, white arrow).
OCT pullback was performed to determine the number of previous stents placed in the LAD and characterize the morphology of the lesion. OCT imaging confirmed in-stent restenosis and revealed fibrous intimal hyperplasia that spanned the mid LAD with a minimum lumen area of 3.08 mm2 (Figure 2B, asterisks represent intimal hyperplasia). Two stent layers were detected proximal to the bifurcation lesion (Figure 2A, arrow colors correspond to stent layers). The severely narrowed D1 ostium (Figures 2C and 3, arrows) is further illustrated using OCT 3D rendering (Figure 4, white arrow). OCT findings of two stent layers and minor calcification within the intimal hyperplasia helped guide the treatment of the LAD bifurcation lesion with a 3.25×6 mm cutting balloon followed by 2.5×15 DES in D1 using TAP provisional stenting technique followed by final kissing balloon inflation (FKBI).
Post-PCI angiography showed improved main vessel and side branch stenoses (Figure 5, arrows), and OCT pullback demonstrated good stent apposition and expansion, as well as an unobstructed D1 ostium in 2D view (Figure 6B and 7, arrows) and 3D reconstruction (Figure 8, white arrow). Post-atherotomy minimal lumen area was assessed to be 4.18 mm2 (Figure 6A). Imaging of mid LAD reveals post-CBA intimal flaps (Figure 6C, arrows).

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