Effectiveness of directional coronary atherectomy in treating recurrent in-stent restenosis: A case report

In-stent restenosis (ISR) remains a significant clinical problem. It is estimated that 10-20% of patients who develop a first event of ISR will develop recurrent ISR (R-ISR). However, the pathology of R-ISR remains largely unknown, and recommendations for its optimal management are lacking. In this case report, we discuss the effectiveness of directional coronary atherectomy (DCA) as an atherectomy device and the mechanism of R-ISR based on pathological findings obtained from DCA. We report the case of a 62-year-old man with a history of ST-segment elevation myocardial infarction treated with percutaneous coronary intervention (PCI) to the mid left circumflex artery using a bare-metal stent. Even after introduction of adequate secondary prevention therapy for ISR, the patient underwent a total of six PCI sessions over 10 years following primary PCI for R-ISR. Eventually, the decision was made to institute treatment with DCA and a drug-coated balloon (DCB). No symptoms of restenosis were observed over the following four years. In this case report, we demonstrate the effectiveness of DCA treatment for debulking a wide range of collagen-rich plaques and show that DCA treatment should be considered for the treatment of R-ISR.