TREATMENT OF IN-STENT RESTENOSIS WITH HIGH-SPEED ROTATIONAL ATHERECTOMY AND IVUS GUIDANCE IN SMALL LESS-THAN-3.0 MM VESSELS

The management of in-stent restenosis remains a subject for debate bec ause no one revascularization option is considered the most appropriat e. Since a high restenosis rate still occurs after repeat balloon angi oplasty, new techniques are attempted in order to reduce this rate. A combination of high speed rotational atherectomy (HSRA) and adjunctive balloon angioplasty is likely to achieve good results. In small (<3.0 mm diameter) vessels, the risk of interaction between the burr and th e stent increases, We thus used intravascular ultrasound (IVUS) guidan ce in the treatment of in-stent restenosis with HSRA in small <3.0 mm small diameter vessels. Nine patients with in-stent restenosis in smal l vessels were referred for repeat angioplasty. Initial IVUS examinati on was used to assess the minimal stent struts diameter and to guide t he burr size selection. A combination of HSRA and additional balloon a ngioplasty was performed under IVUS and angiographic guidance. Mean an giographic reference diameter was 2.25 +/- 0.35 mm and mean stent stru ts diameter was 2.38 +/- 0.20 mm, Burr size was selected similar to 0. 5 mm smaller than stent struts diameter and ranged from 1.75 to 2.5 mm , with a 0.88 +/- 0.12 mean burr/artery ratio (range 0.71, 1.08). In t wo patients, a second larger burr was used. In 4/9 patients, the burr size chosen under IVUS guidance was close to angiographic MLD at stent implantation and thus larger than what would be used without IVUS gui dance, Additional balloon angioplasty was decided in all cases, using a 1.1 +/- 0.15 balloon/artery ratio, No complication occurred. Mean re lative gain in minimal lumen diameter (MLD) was 94 +/- 90% after HSRA and 54 +/- 34% after balloon angioplasty (total relative gain 180 +/- 100%). IVUS guidance allowed safe management of in-stent restenosis in small vessels using combination of HSRA and balloon angioplasty. Long -term follow-up and comparison with other techniques are necessary to assess whether this technique should be used routinely. (C) 1998 Wiley -Liss, Inc.