Diagnosis and management challenges of in-stent restenosis in coronary arteries

Figure 2 Sixty-seven-year-old man presented with increasing chest pain at rest. He has past medical history significant for coronary artery disease with PCI and coronary artery bypass grafting. He had PCI with (3.0 mm × 12 mm) DES to LCx, (2.5 mm × 16 mm) DES to RI and (2.5 mm × 16 mm) DES to obtuse marginal a year prior to his presentation. The left internal mammary artery to LAD is patent, however, he is known to have occluded SVG to RI and SVG to first diagonal (D1). Given his increasing chest pain, coronary angiogram was done. A: Coronary stents before contrast injection in LAD (red arrow), LCx (blue arrow); B: Coronary angiogram of the same patient showing severe proximal LCx ISR (blue arrow) with no flow, severe proximal RI ISR (green arrow) with slow flow, and mid LAD severe ISR (red arrow); C: Dilation of the RI coronary artery with 2.5 mm × 22 mm NC balloon with 22 atm inflation pressures was done; D: Coronary angiogram showing the proximal RI ISR (green arrow) post balloon dilation. Red arrow shows severe proximal LAD stenosis with poor flow. LCx has completely occluded ISR (blue arrow); E: The left circumflex ISR lesion (red arrow) was wired and with balloon dilation the flow was restored in the LCx (green arrow); F: IVUS imaging of the underexpanded stent in the proximal LCx lesion. Left panel shows stent struts (red arrow) with evidence of neointimal hyperplasia (yellow star). The right panel shows small stent CSA of only 3.6 mm² which is below the target 5 mm² in asians and 6 mm² in non-asians; G: IVUS imaging of the underexpanded stent in the proximal ramus coronary artery. Left panel shows severely under-expanded stent (red arrow) with evidence of neointimal hyperplasia (yellow star). The right panel shows small stent CSA of only 2.9 mm²; H: Excimer Laser Coronary Angioplasty treatment of LCx (left panl - red arow) and ramus artery (right panel - green arrow) using 0.9 mm coronary laser and the heparinized flush technique. Laser catheter was advanced slowly at 0.2-0.5 m/s during laser emission with careful monitoring of heart rate and blood pressure. Vessel injury such as perforation, dissections and acute closure are the main side effects; I: Post laser balloon dilation with (3.5 mm × 20 mm) NC balloon of both LCx (red arrow) and ramus (green arrow) arteries; J: Sequential kissing stenting technique in the proximal LCx and ramus arties with DES 3.5 mm x 18 mm in Ramus and 3.5 mm × 15 mm in LCx; K: IVUS imaging of the stent in the proximal LCx coronary artery that shows good expansion of the stent with great increase in CSA to 5.9 mm²; L: IVUS imaging of the stent in the proximal ramus coronary artery that shows good expansion of the stent with great increase in CSA to 5.6 mm²; M: TIMI III flow was achieved in the LCx and Ramus coronary arteries without any compromise of LAD. PCI: Percutaneous coronary intervention; DES: Drug-eluting stents; LCx: Left circumflex; RI: Ramus intermedius; LAD: Left anterior descending artery; SVG: Saphenous vein graft; ISR: In-stent restenosis; NC: Non-compliant; IVUS: Intravascular ultrasound; CSA: Cross-sectional area.