RT Book, Section A1 Alraies, M. Chadi A1 Waksman, Ron A2 Baliga, R. R. A2 Lilly, Scott M. A2 Abraham, William T. SR Print(0) ID 1160206886 T1 In-Stent Restenosis T2 Color Atlas and Synopsis of Interventional Cardiology YR 2018 FD 2018 PB McGraw-Hill Education PP New York, NY SN 9780071749350 LK accesscardiology.mhmedical.com/content.aspx?aid=1160206886 RD 2024/03/29 AB A 67-year-old man with a past medical history significant for insulin-dependent diabetes mellitus, hypertension, and coronary artery disease was admitted with typical angina (Canadian Cardiovascular Society [CCS] class III) for 1 month. The patient had a history of acute non–ST-segment elevation myocardial infarction (NSTEMI) 12 months prior to his presentation and was treated with a total of 5 drug-eluting stents in the left anterior descending (LAD), left circumflex (LCx), and right coronary (RCA) arteries. The patient was compliant with dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). During the current admission, the patient had dynamic electrocardiogram (ECG) changes in anterolateral leads with elevated troponin I. Echocardiography revealed a hypokinetic left ventricular (LV) apex with estimated left ventricular ejection fraction (LVEF) of 45%. The patient underwent coronary angiogram that showed severe diffuse in-stent restenosis (ISR) in the proximal LAD stent and moderate ISR in the diagonal stent (bifurcation lesion) along with significant ostial disease in the LAD extending from the upper edge of the LAD stent. Kissing balloon inflations were performed using a 2.5 × 15 mm sapphire noncompliant (NC) balloon in the LAD and a 2 × 10 mm sapphire balloon in the diagonal branch. Keeping the guidewire in the LAD, the LCx was wired using a BMW guidewire. A Xience V (Abbott, Chicago, IL) 2.75 × 12 mm stent was positioned in the ostioproximal LAD overlapping the distal stented segment (see Figure 17-3, red arrow) and deployed at 18 atm, keeping an uninflated 2 × 10 mm sapphire balloon in the distal left main and ostial LCx. The overlapped segment was postdilated using the same in-stent balloon at 20 atm. Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow was achieved in the LAD without any compromise of ostial LCx.