Visualization of the delivery of a paclitaxel-urea coating matrix by intravascular ultrasound following drug-eluting balloon angioplasty for in-stent restenosis

Abstract We present the case of a patient with unstable angina due to in-stent restenosis (ISR) of a second-generation drug-eluting stent (DES) implanted in the left anterior descending artery ten months prior. Intravascular ultrasound (IVUS) showed stent underexpansion and inflow and outflow obstructive lesions. A hybrid approach was applied, comprising implantation of DES across the lesions at the stent edges and paclitaxel drug-coated balloon (DCB) angioplasty of the body of the stent, which had previously been properly expanded. Five months later, the patient was readmitted with unstable angina. Angiography showed ISR of the DES implanted across the edges of the old stent and preserved patency of the lumen corresponding to the body of the old stent, which was treated with DCB angioplasty. The latter was ascribed to the efficient delivery of paclitaxel to the arterial wall, which was potentially suggested by a continuous intimal hyperechoic layer seen on IVUS immediately following DCB angioplasty. Due to recurrent ISR of the LAD artery and functionally significant ISR of the LCx artery, the patient underwent surgical revascularization with a good outcome.