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Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 28-31  

Optical coherence tomography in in-stent restenosis: A challenge made easier

Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication7-May-2019

Correspondence Address:
Dr. Mahim Saran
Department of Cardiology, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None


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In-stent restenosis (ISR) has been an area of concern for the interventional cardiologists since the era of bare-metal stents (BMS). Although the incidence of ISR is more with BMS as compared to drug-eluting stents, due to the underlying pathophysiological differences, between the two; the latter has a more accelerated course and is difficult to treat. In this case report, we try to address this issue of difficult treatment of ISR and the benefit of using optical coherence tomography in these situations.

Keywords: Drug-eluting stent, in-stent restenosis, minimum stent area, optical coherence tomography

How to cite this article:
Pradhan A, Saran M, Vishwakarma P, Sethi R. Optical coherence tomography in in-stent restenosis: A challenge made easier. Heart Views 2019;20:28-31

How to cite this URL:
Pradhan A, Saran M, Vishwakarma P, Sethi R. Optical coherence tomography in in-stent restenosis: A challenge made easier. Heart Views [serial online] 2019 [cited 2022 Jul 3];20:28-31. Available from: https://www.heartviews.org/text.asp?2019/20/1/28/257794

   Introduction Top

In-stent restenosis (ISR) has been an area of concern for the interventional cardiologists since the era of bare-metal stents (BMS).[1] Drug-eluting stents (DES) have shown some promise in reducing the incidence of ISR, especially in the first 6 months.[2] However, with the increasing use of stents in complex and long lesion in high-risk patients, ISR continues to be a common complication.[3]

The incidence of ISR has been shown to be 30.1%, 14.6%, and 12.2% for BMS, first-generation DES, and second-generation DES, respectively.[4]

The morphology of ISR in DES differs from BMS being focal in the former in contrast to proliferative in the latter.[5] The difference in morphology can be attributed to the underlying pathophysiology, which is predominantly neointimal hyperplasia in BMS-ISR and neoatherosclerosis in Drug eluting stent-in stent restenosis (DES-ISR).[6] Neoatherosclerosis occurs earlier in DES-ISR and has a more accelerated course.[6] Thus, DES-ISR though focal is difficult to treat as compared to BMS-ISR.[5]

In this case report, we try to address this issue of difficult treatment of ISR and the benefit of using optical coherence tomography (OCT) in these situations.

   Case Presentation Top

A 46-year-old gentleman presented to the emergency department with a history of chest pain and was diagnosed as non-ST-elevation myocardial infarction (NSTEMI) in September 2016. He underwent coronary angiography and stenting of the proximal left anterior descending artery with 2.75 mm × 24 mm sirolimus DES. He was apparently asymptomatic and under regular follow-up for the next 2 years when he presented to the emergency department again with similar rest angina and was diagnosed as NSTEMI. He underwent coronary angiography which revealed a diffuse Type II ISR [Figure 1] and [Figure 2].
Figure 1: Coronary angiogram in the left anterior oblique caudal view showing in-stent restenosis in the left anterior descending stent

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Figure 2: Coronary angiogram in the right anterior oblique caudal view showing in-stent restenosis in the left anterior descending stent

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Intravascular imaging with OCT was carried out which showed in-stent diffuse backscattering lesion with minimum stent area of 2.62 mm2 which could be either due to an underexpanded stent or probably malapposed struts at 4–6 o'clock positions [Figure 3]. Furthermore, there were areas of low-backscattering projections suggestive of a white thrombus which could be attributed to plaque erosion as a cause of NSTEMI. The lesion was predilated with 2.5 mm × 10 mm semi-compliant balloon at 12-atmosphere pressure followed by stenting with 2.75 mm × 33 mm everolimus DES and postdilated with 3 mm × 10 mm noncompliant balloon at 16-atmosphere pressure. Repeat OCT poststenting was carried out, which showed good apposition and minimum stent area of 4.97 mm2 with no evidence of underexpansion or geographical miss [Figure 4]. The results were acceptable and showed TIMI III flow [Figure 5]. The patient was discharged in a hemodynamically stable and pain-free condition.
Figure 3: Optical coherence tomography image prestenting showing diffuse backscattering by lesion and stent underexpansion (4–6 o'clock positions)

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Figure 4: Optical coherence tomography image poststenting showing good expansion and apposition

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Figure 5: Final result poststenting in the left anterior oblique caudal view

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   Discussion Top

ISR has been the Achilles heel of interventional cardiology, and multiple treatment modalities have been proposed for this condition. Initially, ISR used to be considered a benign condition which progresses slowly and presents as a stable disease with good acute results.[7],[8] However, recently, it has been shown that ISR usually presents with unstable symptoms and sometimes even fulfills the criteria of myocardial infarction.[4],[9]

Intravascular imaging is important in these cases, as it may reveal the causes of ISR such as underexpansion, malapposition, or strut fracture. Moreover, OCT can help evaluate the extent and distribution of the neointimal tissue and also characterize the lesion.[10],[11],[12] Neoatherosclerosis in DES usually appears as a nonhomogeneous lesion with microvessels which are difficult to treat.

In our case, OCT was useful in identifying the extent of the lesion as within the stent, and diffuse backscattering was likely due to neointimal hyperplasia. Furthermore, the distal end of the stent was malapposed which was not apparent on angiography in the initial procedure. This might have caused the ISR and symptoms. The minimum stent area was 2.62 mm2. The minimum stent area achieved after postdilatation was 4.97 mm2, and there was no apparent malapposition of the stent.

Angiographic lesion intervention without symptoms (oculostenotic reflex) should be avoided; however, very severe ISR (>75%) should be treated.[13],[14] The criteria to intervene and final optimum result based on minimum luminal area are illustrated in [Table 1].[15],[16],[17],[18],[19] There have been multiple trials evaluating the role of PTCA balloons, drug-eluting balloons (DEB), or radiation therapy. Finally, after pooled meta-analysis of RIBS IV and RIBS V, it was concluded that clinical and angiographic long-term results were superior with everolimus DES when compared with DEB for both BMS-ISR and DES-ISR.[20] With the introduction of DES with very thin struts, the concern of the additional metal layer is low, and introduction of newer generation DEB may be useful in the future.
Table 1: Criteria for intervention and the desired poststenting result based on minimal stent area[15],[16],[17],[18],[19]

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First-choice treatment for ISR remains DES implantation followed by DEB.[21] However, the focus has now shifted from the treatment of ISR to prevention of DES-ISR by optimal bed preparation, adequate lesion coverage, and use of intravascular imaging to guide stent placement and verify proper expansion and good apposition of the stent to the vessel wall. OCT is an important part of evaluation of ISR and optimizing stent placement.

   Conclusion Top

OCT is a feasible and powerful tool in assessing the nature of ISR and guiding treatment. Prevention of ISR by proper bed preparation, adequate lesion coverage, and use of intracoronary imaging to guide stent placement is preferable in complex lesions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Dangas G, Fuster V. Management of restenosis after coronary intervention. Am Heart J 1996;132:428-36.  Back to cited text no. 1
Morice MC, Serruys PW, Sousa JE, Fajadet J, Ban Hayashi E, Perin M, et al. Arandomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 2002;346:1773-80.  Back to cited text no. 2
Stettler C, Wandel S, Allemann S, Kastrati A, Morice MC, Schömig A, et al. Outcomes associated with drug-eluting and bare-metal stents: A collaborative network meta-analysis. Lancet 2007;370:937-48.  Back to cited text no. 3
Cassese S, Byrne RA, Tada T, Pinieck S, Joner M, Ibrahim T, et al. Incidence and predictors of restenosis after coronary stenting in 10 004 patients with surveillance angiography. Heart 2014;100:153-9.  Back to cited text no. 4
Otsuka F, Byrne RA, Yahagi K, Mori H, Ladich E, Fowler DR, et al. Neoatherosclerosis: Overview of histopathologic findings and implications for intravascular imaging assessment. Eur Heart J 2015;36:2147-59.  Back to cited text no. 5
Alfonso F, Byrne RA, Rivero F, Kastrati A. Current treatment of in-stent restenosis. J Am Coll Cardiol 2014;63:2659-73.  Back to cited text no. 6
Alfonso F. Treatment of drug-eluting stent restenosis the new pilgrimage: Quo vadis? J Am Coll Cardiol 2010;55:2717-20.  Back to cited text no. 7
Alfonso F, Pérez-Vizcayno MJ, Cruz A, García J, Jimenez-Quevedo P, Escaned J, et al. Treatment of patients with in-stent restenosis. EuroIntervention 2009;5 Suppl D: D70-8.  Back to cited text no. 8
Chen MS, John JM, Chew DP, Lee DS, Ellis SG, Bhatt DL, et al. Bare metal stent restenosis is not a benign clinical entity. Am Heart J 2006;151:1260-4.  Back to cited text no. 9
Gonzalo, N. Serruys PW, Regar E. Optical coherence tomography: Clinical applications and the evaluation of DES. Minerva Cardioangiol 2008;56:511-25.  Back to cited text no. 10
Gonzalo N, Barlis P, Serruys PW, Garcia-Garcia HM, Onuma Y, Ligthart J, et al. Incomplete stent apposition and delayed tissue coverage are more frequent in drug-eluting stents implanted during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction than in drug-eluting stents implanted for stable/unstable angina: Insights from optical coherence tomography. JACC Cardiovasc Interv 2009;2:445-52.  Back to cited text no. 11
Meissner OA, Rieber J, Babaryka G, Oswald M, Reim S, Siebert U, et al. Intravascular optical coherence tomography: Differentiation of atherosclerotic plaques and quantification of vessel dimensions in crural arterial specimens. Rofo 2006;178:214-20.  Back to cited text no. 12
Pinto DS, Stone GW, Ellis SG, Cox DA, Hermiller J, O'Shaughnessy C, et al. Impact of routine angiographic follow-up on the clinical benefits of paclitaxel-eluting stents: Results from the TAXUS-IV trial. J Am Coll Cardiol 2006;48:32-6.  Back to cited text no. 13
Uchida T, Popma J, Stone GW, Ellis SG, Turco MA, Ormiston JA, et al. The clinical impact of routine angiographic follow-up in randomized trials of drug-eluting stents: A critical assessment of “oculostenotic” reintervention in patients with intermediate lesions. JACC Cardiovasc Interv 2010;3:403-11.  Back to cited text no. 14
Kang SJ, Lee JY, Ahn JM, Song HG, Kim WJ, Park DW, et al. Intravascular ultrasound-derived predictors for fractional flow reserve in intermediate left main disease. JACC Cardiovasc Interv 2011;4:1168-74.  Back to cited text no. 15
de la Torre Hernandez JM, Hernández Hernandez F, Alfonso F, Rumoroso JR, Lopez-Palop R, Sadaba M, et al. Prospective application of pre-defined intravascular ultrasound criteria for assessment of intermediate left main coronary artery lesions results from the multicenter LITRO study. J Am Coll Cardiol 2011;58:351-8.  Back to cited text no. 16
Kang SJ, Ahn JM, Song H, Kim WJ, Lee JY, Park DW, et al. Comprehensive intravascular ultrasound assessment of stent area and its impact on restenosis and adverse cardiac events in 403 patients with unprotected left main disease. Circ Cardiovasc Interv 2011;4:562-9.  Back to cited text no. 17
Koo BK, Yang HM, Doh JH, Choe H, Lee SY, Yoon CH, et al. Optimal intravascular ultrasound criteria and their accuracy for defining the functional significance of intermediate coronary stenoses of different locations. JACC Cardiovasc Interv 2011;4:803-11.  Back to cited text no. 18
Sonoda S, Morino Y, Ako J, Terashima M, Hassan AH, Bonneau HN, et al. Impact of final stent dimensions on long-term results following sirolimus-eluting stent implantation: Serial intravascular ultrasound analysis from the sirius trial. J Am Coll Cardiol 2004;43:1959-63.  Back to cited text no. 19
Alfonso F, Pérez-Vizcayno MJ, García Del Blanco B, García-Touchard A, Masotti M, López-Minguez JR, et al. Comparison of the efficacy of everolimus-eluting stents versus drug-eluting balloons in patients with in-stent restenosis (from the RIBS IV and V randomized clinical trials). Am J Cardiol 2016;117:546-54.  Back to cited text no. 20
Sethi A, Malhotra G, Singh S, Singh PP, Khosla S. Efficacy of various percutaneous interventions for in-stent restenosis: Comprehensive network meta-analysis of randomized controlled trials. Circ Cardiovasc Interv 2015;8:e002778.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1]


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