AngioClub: A Multimodality Approach to Recalcitrant In-Stent Restenosis

CathMasters (Drs. Amit Goyal, Daniel Ambinder, Nazli Okumus, and Salman Allana) discuss a challenging case of recalcitrant focal in-stent restenosis (ISR) within two layers of stent in a right coronary artery. The panel walks through a systematic approach to ISR: guide selection and access strategy; the role of intracoronary imaging in classifying ISR using the Waksman mechanistic classification; and a stepwise lesion-modification algorithm using cutting balloons, excimer laser coronary atherectomy (ELCA), and intravascular lithotripsy (IVL). The discussion concludes with the contemporary role of drug-coated balloons (DCB) versus vascular brachytherapy (VBT), and when to consider rotational atherectomy (RA) for stent ablation in refractory cases.