Optical coherence tomography for guidance of treatment of in-stent restenosis with cutting balloons

Aims: The treatment of in-stent restenosis (ISR) remains a challenge with poor immediate results and higher restenosis rate than in de novo lesions. We propose, based on a consecutive series of patients treated with cutting balloon, a strategy of aggressive device selection based on the results of serial FD-OCT assessment. Methods and results: Fourteen consecutive ISR lesions were evaluated both angiographically and with frequency domain optical coherence tomography (FD-OCT) (C7; LightLab Imaging Inc., Westford, MA, USA). Cutting balloon (CB) was used in all cases, sized firstly according to conventional angiographic criteria and then upgraded based on OCT assessment with the aim of creating cuts as close as possible to the struts. OCT data analysis included measurements of lumen and stent area, minimal distance lumen-struts and residual plaque neointimal hyperplasia. With an OCT guided CB strategy, the final minimal lumen cross-sectional area (MLCSA) after the final treatment reached 6.68±1.14 mm2, with a reduction from 69% to 25% of neointimal hyperplasia. In the patients with a two-step strategy using a first CB guided by angiography and a second CB guided by OCT, the increase in CB diameter was 0.5 mm, achieving an increase in MLCSA area from 4.9±0.42 to 6.35±0.92 mm2 with a reduction from 41% to 27% of neointimal hyperplasia. Conclusions: The OCT measurements of strut-to-strut distance allow safe upsizing of the CB with an acceptable lumen increase before deployment of a new DES. The strategy appears of particular usefulness for a DEB strategy with no intention to implant new stents.