OCT Guided PCI of DES-ISR CTO

A 57-year-old man, current smoker, with a history of hypertension, hyperlipidemia and known three- vessel disease status post multiple PCIs (mid-RCA, distal-RCA, mid-LAD, D1) presented with ongoing anginal chest pain and subsequently referred to us for RCA DES-ISR CTO lesion intervention.

Coronary angiography revealed ISR of mid-RCA (CTO) and distal-RCA (90-95%) lesion (Figure 1A, 1B). CTO lesion was crossed with Fine Cross micro-catheter and Fielder wire, subsequently using rotational atherectomy (RA) with 1.50 mm burr for 60 sec and 2.00mm burr for 60 sec at 150,000 rpm (Figure 1C) followed by balloon angioplasty (Figure 1D) and OCT pullback.

ISR remains a challenging clinical problem with DESs. The use of intracoronary imaging modalities helps characterize the mechanisms of how restenosis develops. Recently, a new classification system has been developed to guide the selection of appropriate therapeutic strategies for the management of patients with DES-ISR.¹ In this case, OCT was used to classify the type of the DES-ISR lesion as a Type II Biologic, neoatherosclerosis with calcification, and subsequently determine the optimal treatment option.