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| CASE REPORT |
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| Year : 2019 | Volume
: 20
| Issue : 1 | Page : 28-31 |
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Optical coherence tomography in in-stent restenosis: A challenge made easier
Akshyaya Pradhan, Mahim Saran, Pravesh Vishwakarma, Rishi Sethi
Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India
| Date of Web Publication | 7-May-2019 |
Correspondence Address:
Dr. Mahim Saran
Department of Cardiology, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_6_19
 Abstract | | |
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 2021 Sep 20];20:28-31. Available from: https://www.heartviews.org/text.asp?2019/20/1/28/257794 |
| Introduction | |  |
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 | | |
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 | | |
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 | | |
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1]
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