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Operators: Annapoorna Kini, MD and Samin Sharma, MD
Fellows: Gurpreet Johal, MD and Htoo Kyaw, MD

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.

OCT images showed neoatherosclerosis (noncalcified) in distal-RCA with MLA 1.41 mm2 (Figure 2A) and neoatherosclerosis (calcified) after calcium debulking by RA in mid-RCA (Figure 2B). We performed pre-dilation with NC Emerge 3.0x20mm followed by deployment of a 3.5×38 mm DES. In the pullback, four quadrant calcium can be appreciated in-between the frames of 2A and 2B, around the 20mm mark.
Post-dilation with NC-Emerge 3.5x20mm was performed with post-stent OCT showing good stent apposition and expansion (Figure 3D). Small tissue prolapse was seen but no dissection was found at the stent edge (Figure 3B and C).

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.

  1. Shlofmitz E, Iantorno M, Waksman R. Restenosis of Drug-Eluting Stents: A New Classification System Based on Disease Mechanism to Guide Treatment and State-of-the-Art Review. Circ Cardiovasc Interv. 2019;12:e007023

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