Multi-Modality Treatment of 2-Layer In-stent Restenosis
Presenter
Aaron A Shaikh, MD, Lahey Hospital and Medical Center, Burlington, MA
Aaron A Shaikh, MD, Lahey Hospital and Medical Center, Burlington, MA
Keywords: Complex and High-risk Coronary Intervention (CHIP), Coronary, Drug-eluting Stent (DES), Imaging & Physiology and Intravascular Lithotripsy (IVL)
Title
Multi-Modality Treatment of 2-Layer In-stent Restenosis
Introduction
69-year-old male with a past medical history of anterior STEMI in 2014 complicated V-fib arrest s/o PCI to the mid LAD at an OSH, followed by severe in-stent restenosis one month later treated with an additional layer of stent in the mid LAD, ischemic cardiomyopathy with an LVEF of 35%, atrial fibrillation on rivaroxaban who suffered from recurrent life limiting angina despite maximally tolerated optimal medical therapy.
Clinical Case
2 layer ISR assesed with OCT and treated with imaging-guided PCI.
Discussion
/Take Home Points:
1.Pre-PCI intravascular Imaging (IVI) is Essential for Management of ISR
- Identifies mechanism of ISR: DES under expansion vs. NIH and Neoathersclerosis
- Identifies plaque morphology: fibrotic tissue, thrombosis, calcification
2.Treatment Strategy of ISR Should Be Based on IVI
- Often several plaque morphologies in one lesion requiring multi-modality treatment strategy
-This case: cutting balloon angioplasty, laser atherectomy, Shockwave IVL, NC balloon angioplasty 3.Post-PCI IVI Allows of Quantification of Treatment Success
- OCT and IVUS can reveal significant luminal gain that may not be apparent on angiography
4.Treatment of Two-Layer ISR with Calcification
- IVL (Shockwave) can help to achieve greater luminal gain by fracturing deep wall Ca2+ between and/or behind two layers of stent.