Severe in-stent restenosis due to two stent layers: A case report

Background: The prevalence of in-stent restenosis is around 3-10%. One treatment option for re-stenosis is implantation of another drug eluting stent, the so-called "sandwich strategy". Multiple stent layers can potentially reduce the penetration of antiproliferative drugs into the vessel wall, thereby minimizing the effect of the drug. In this clinical case, we encountered restenosis after a previously implanted stent for treatment of restenosis.Case presentation: A 73-year-old female with previous history of RCA stenting in 2019 due to myocardial infarction. In 2020, RCA restenosis was identified and RCA PCI was performed (Supraflex 2.75x28mm, XienceXpedition 3.5x38mm). The current hospitalization was associated with a recurrence of dyspnea on exertion. Coronary angiography revealed an 80% restenosis of the RCA. A decision was made to perform ultra-high-pressure balloon for this lesion. A stent-boost image was obtained showing stent deformation. Balloon angioplasty was performed using a 3.5x15mm ultra-high-pressure balloon OPN NC (SIS Medical, Switzerland) at 40 atm. Control angiography showed a restoration of vessel lumen. IVUS showed minimal lumen area (MLA) of 8.37 mm2. Six months later cause of a recurrence of dyspnea on exertion a myocardial scintigraphy was performed, which revealed an ischemic zone of 20-25%. Based on these results, angiography was performed which identified recurrent restenosis in the same segment. IVUS-guided angioplasty with a 4.0x15mm OPN NC in combination with a 4.0x30mm Agent drug-coated balloon (DCB) was performed with inflation at 6 atm for 60 seconds. This resulted in good angiographic results, with an MLA of 9.76mm² and optimal stent expansion throughout.Conclusion: Treatment of patients with restenosis remains a challenging task. Intravascular imaging is a fundamental factor in restenosis management, allowing determination of restenosis type and selection of optimal treatment strategy to achieve satisfactory results and reduce the risk of repeat interventions. Therefore, the combination of intravascular imaging and dedicated devices is strongly suggested for a more standardized approach for in-stent restenosis.