Interventional Cardiologist | Specializing in Complex PCI & CTO Interventions | Advancing Structural Heart Therapies - Amsterdam UMC Hartcentrum
Seeking help regarding a challenging case of recurrent in-stent restenosis that has proven resistant to conventional management. The patient has experienced three episodes of in-stent restenosis affecting two different coronary territories, despite sequential trials of multiple P2Y12 inhibitors (Brilinta, Effient, and Plavix) with confirmed good compliance. IVUS evaluation demonstrates optimal stent deployment with good expansion, proper wall apposition, and no identifiable mechanical issues. Despite optimized medical therapy and proper stent deployment, we continue to see recurrent ISR. What is your suggestion ?
Sholy Haitham
1mo
Consider colchicine treatment
Sholy Haitham
1mo
If it's one layer stent I would implant stent in stent. If it's a case of two layers I would try sirolimus DCB
Rocco Giunta
1mo
Maybe laser could be an option in ISR. You can try my friend
Bilal Iqbal
1mo
1. If imaging repeatedly shows good result and you still have recurrent ISR, then consider underlying inflammation. Exclude underlying autoimmune disease. Colchicine can help. 2. If recurrent ISR in LAD then LIMA to LAD is good option. 3. If recurrent ISR in nonLAD then can (reluctantly) consider CABG but before that I would try 4. 4. Work around the site of ISR into the EP space then and then a new stent around it in EP space. I have used with good outcomes in few patients now, ie patients no longer present with angina, which they did before every 3-6 months!
Ioannis Felekos
1mo
Once mechanical reasons have been excluded , then you re dealing with agressive CAD. I would definitely avoid another layer of metal. DCB likely an option , brachytherapy another ( if available ) . DAPT does not prevent ISR , is only for stent thrombosis . Also please ensure that you optimize lipids - aim for LDL less than 55 mg/dl if you can and tight glycemic control (if you patient is diabetic).CABG would be an option for LAD
Sebastian Bader
1mo
What was the mechanism of in-stent restenosis if there was no stent-related problem (fracture, malapposition, underexpansion etc)? Intimal hyperplasia? Underlying calcified nodule? What kind of stent plattform did you use? Different types? Are there any known allergies of the patient? I am thinking outside the box of very rare contact allergy to the cobalt/chrome of the stent (although there is very little data to my knowledge)? Maybe a BRS (like Freesolve Biotronik) or a stent with a good radial force can help. Colchicine might also help, as options seem to become less and CABG seems to be waiting at the end of the tunnel 🙈
Lorenzo Azzalini
1mo
What’s the mechanism of ISR? Imaging should guide management. If there’s under expansion, that should be addressed (IVL, OPN, atherectomy). If there’s only NIH, and different DEBs have failed, IVBT (only available in the US) or CABG are the remaining options. Also, platelets have nothing to do with ISR, so P2Y12i won’t work.
It seems that you have thought well and implemented most of the suggested recommendations above. Though uncommon, such difficult cases can be encountered and they are obviously difficult to manage. The Colchicine idea is worth trying. The recommendations remain anecdotal. In case you used DCBs with only one platform (Paitaxel), could it help to try DCB with a Sirolimus platform? In the literature vascular brachytherapy is recommended in refractory cases with long term DAPT because of delayed endothelialization (I don’t have any experience with it). I subscribe to most of the thoughts shared above at first hand which I think you already have done. Thank you for sharing this interesting case.
Do not forget Colchicine Our associate in Fundación Epic, Iñigo Lozano has a long and dilated experience In this field, near to a start a new clinical trial Just some information about https://pmc.ncbi.nlm.nih.gov/articles/PMC10265483/
Head Of Cardiology, Siun Sote Professor of Cardiology, University of Eastern Finland
1moThis is of course thinking out of the box and in retrospect in this case - but my friend Simon Eccleshall has said that primary prevention of ISR is doing dcb and secondary prevention of ISR is doing dcb. Honestly, restenosis after dcb is easier because you have all the options left for plaque modification. Sometimes for ISR I have used off lable two paclitaxel DCBs to have higher drug concentration. Or limus and paclitaxel dcbs. Rarely, CABG is the only option.