Managing Patients With Intermediate In-Stent Restenotic Lesions

The importance of intravascular ultrasound (IVUS) as an adjunctive technology facilitating optimal coronary interventional procedural technique has become increasingly evident over the past decade. IVUS is currently appreciated as an invaluable tool enabling better assessment of reference vessel size and coronary lesion morphology, including gross plaque characteristics and lesion length. Accordingly, the adjunctive use of IVUS with angiography offers distinct advantages in the setting of performing coronary interventions.1 The structural information acquired by ultrasound imaging has helped us plan and better execute the optimal coronary interventional procedures to achieve improved procedural efficiency and outcomes. These benefits have become more critical as we progressively approach more complex coronary lesions with catheter-based therapies. In addition, IVUS has shown to be a useful tool to investigate other possible structural causes relating to adverse events, including stent thrombosis. Late-acquired stent malapposition, stent fracture, inadequate lesion coverage, and excessive stent overlap are all readily detected by IVUS.Article see p 111 The most recent ACC/AHA/SCAI percutaneous coronary intervention (PCI) guidelines2 equivocally address the use of preinterventional IVUS for the assessment of lesion characteristics and vessel dimensions as a means to select an optimal revascularization strategy (class IIb, level of evidence C). The importance of IVUS in assessing postprocedural results appears to be more clearly defined. Appropriate stent expansion, optimal wall apposition, and detection of postdeployment stent edge issues, such as dissections, are all well assessed by IVUS.3 Evaluation of these anatomic features has possible implications regarding the safety and efficacy of PCI.4,5 Current ACC/AHA/SCAI PCI guidelines2 support IVUS use to assess postinterventional results (class IIa, level of evidence B).The role of IVUS in the long-term post-PCI management of patients with in-stent restenosis remains to be established. Once …