Three‐Year Clinical Outcomes of IVUS‐Guided Excimer Laser Coronary Atherectomy for In‐Stent Restenosis

Background In‐stent restenosis (ISR) remains challenging after percutaneous coronary intervention (PCI) using drug‐eluting stents, often leading to target lesion revascularization (TLR) and major adverse cardiovascular and cerebrovascular events (MACCEs). Excimer laser coronary atherectomy (ELCA) removes neointimal tissue and preserves minimum lumen area (MLA); however, its long‐term benefits are unclear. Aims We assessed the 3‐year outcomes of PCI with or without ELCA for ISR and examined prognostic factors and intravascular ultrasound (IVUS) findings. Methods We retrospectively analyzed data of 97 patients with ISR among 2083 consecutive patients who underwent PCI between April 2020 and March 2025. Patients were divided into ELCA ( n = 44) and non‐ELCA ( n = 53) groups. Outcomes were analyzed using Kaplan–Meier and log‐rank tests. The primary outcome was all‐cause mortality. Secondary outcomes included TLR and MACCE rates. IVUS characteristics were also assessed. Results Baseline characteristics were generally similar between groups, although acute coronary syndrome was more frequent in the non‐ELCA group. All‐cause mortality did not differ significantly between groups ( p = 0.699). TLR was numerically lower in the ELCA group (0% vs. 7.5%, p = 0.062). MACCEs were significantly less frequent in the ELCA group (2.3% vs. 18.9%, p = 0.018), and ELCA was independently associated with a lower risk of MACCEs in multivariable Cox analysis. After IPW, ELCA remained significantly associated with a lower risk of MACCEs (odds ratio 0.065, 95% confidence interval 0.006–0.291, p = 0.003). However, event‐specific analyses, particularly for TLR, were limited by sparse events and should be interpreted cautiously. IVUS showed significantly greater lumen enlargement in the ELCA group, and the change in MLA correlated with baseline minimum stent area only in the ELCA group. Conclusions In this retrospective cohort, ELCA was associated with lower MACCE rates and greater lumen enlargement; however, these findings should be considered hypothesis‐generating in light of the nonrandomized design, limited sample size, and imbalance in clinical presentation.