Technical Mastery: Guidance on Proper Imaging, Lesion Preparation, and Deployment for Coronary Drug-Coated Balloons. Part 3: Bringing it All Together: Case Reviews of In-Stent Restenosis-Slides, Dr. Abbott

Slides, Dr. Abbott

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This case study discusses a 64-year-old woman with premature coronary artery disease (CAD) and a complex history including CABG and multiple prior percutaneous coronary interventions (PCIs), resulting in multilayer in-stent restenosis (ISR) in the left circumflex artery (LCx) and obtuse marginal (OM) branches. Despite maximal medical therapy, she presented with escalating angina. Diagnostic catheterization revealed multivessel disease with 50-70% ISR in the LCx and OM1, involving double-layer drug-eluting stents (DES). Fractional flow reserve (RFR) testing confirmed ischemia in these areas.<br /><br />The clinical challenge of managing multilayer ISR lies in the difficulty of optimizing stent expansion and the higher risk of recurrent restenosis with additional stenting. Intravascular imaging (IVUS) and coronary physiology assessments are essential to guide therapy, though advancing imaging catheters can be technically difficult. Various adjunctive techniques such as intravascular lithotripsy (IVL), excimer laser coronary angioplasty (ELCA), high-pressure balloons like OPN, and cutting or scoring balloons may be employed for optimal lesion preparation.<br /><br />Drug-coated balloons (DCB), specifically paclitaxel-coated, offer an alternative therapeutic approach by delivering antiproliferative agents locally without adding further stent layers. The AGENT trial, which stratified patients by single versus multilayer ISR, demonstrated that paclitaxel DCB reduces the risks of target lesion revascularization (TLR), target lesion failure (TLF), and target vessel myocardial infarction (TV-MI) compared to plain old balloon angioplasty (POBA).<br /><br />In this patient, PCI with DCB was successfully performed after lesion preparation, including the use of guide extension catheters for easier delivery. The case underscores that multilayer ISR is a complex scenario requiring tailored strategies leveraging physiology, imaging, advanced lesion modification, and DCB use to improve outcomes without increasing stent layers.

Keywords

premature coronary artery disease

multilayer in-stent restenosis

drug-eluting stents

left circumflex artery

fractional flow reserve

intravascular imaging

intravascular lithotripsy

drug-coated balloons

paclitaxel-coated balloons

percutaneous coronary intervention