The Dilemma of Repeat in Stent Re-stenosis: Can Intravascular Lithotripsy Provide an Alternative Approach to an Age-Old Problem?

Abstract

Background: In-stent restenosis (ISR) has always been considered a conundrum for interventional cardiologists. Despite many technical advances in the last 20 years aimed at reducing its occurrence this area of interventional cardiology remains challenging. Here we present a novel use of IVL in a patient with repeat ISR in whom IVL treatment has provided excellent procedural and follow up results.

Case summary: A 79-year-old man with previous in stent restenosis (ISR) to a left circumflex artery stent presented with angina. Elective coronary angiogram confirmed recurrent ISR in the left circumflex artery (LCX). This was treated by Intravascular Lithotripsy (IVL), which provided an excellent procedural result. The patient made an uneventful recovery and was discharged the same day with follow up 90 days post procedure at which point they were asymptomatic from angina.

Conclusion: Despite advances in the development of plaque modifying therapy, management of in-stent restenosis due to heavy calcium burden and fibrotic coronary stenosis, remains difficult, challenging, and often requires adjuvant interventional tools and techniques. However, to date the outcomes of treating in stent re stenosis have been sub optimal and often lead to recurrence of symptoms for the patient. IVL is a relatively simple technique to modify ISR with a short learning curve. This case presentation highlights a novel use of IVL in a sub class of patients that remain challenging for the interventional cardiology community.