1. Dr Adrian Banning, The John Radcliffe, Oxford Drug eluting stents for in-stent restenosis

2. Case Presentation (1) 44-year old man August 2001 –presents with Unstable Angina, –severe LAD stenosis. Direct stent - 3.5x15 NIR Elite October 2001: –recurrent angina, –severe stenosis just proximal to the stent. – 3.5x8 Express, partially overlapping the first April 2002: –recurrent angina - diffuse in-stent restenosis. CABG with LIMA->LAD

3. Case Presentation August 2001 stent October 2001: stent April 2002: CABG with LIMA->LAD, June 2002 –Recurrent angina –Management? –Exercise test on treadmill?

5. Case Presentation (2) August 2002: –cath - failed LIMA graft- –enrolled in a multicenter registry (non-polymeric paclitaxel DES at concentration of 3.0 µg/mm2 DELIVER II ) –2 “Achieve” stents 3.5x18 and 3.5x23 mm in the mid LAD Entire previously stented segment was covered –Optimized with high-pressure 3.5 mm NC balloon, no IVUS

6. Case Presentation (2) August 2002: –cath - failed LIMA graft- –enrolled in a multicenter registry (non-polymeric paclitaxel DES at concentration of 3.0 µg/mm2 DELIVER II ) –2 “Achieve” stents 3.5x18 and 3.5x23 mm in the mid LAD Entire previously stented segment was covered September 2003 (13 months) recurrent angina –Further angiogram –5 th in 22 months

7. September 2003 PRE-INTERVENTION

8. September 2003 Intervention number 4 –IVUS guidance Cypher 3.0x23 and 3.0x23 covering all the previously stented segment with overlap. 3.5 NC balloon multiple inflations (up to 24 atm) –IVUS used to check MLA>5 mm2

9. September 2003 POST-INTERVENTION

10. April 2004 (8 months post) FOLLOW UP

11. April 2004 (8 months post) FOLLOW UP

12. What is “in stent restenosis” Densely packed neointima mainly VSMC and matrix Like a keloid scar Not atheroma

15. The pre-DES era

16. Treatment modality does not matter

17. Vascular brachytherapy good short term results

19. DES era: a bad start

20. Data from registries

21. Cypher stent: Brazilian and Dutch experience

22. Long term follow-up

23. QCA data: late catch up?

24. IVUS data: reassuring

28. SECURE registry

29. Recurrent ISRNo Rec. ISRp MLA <5mm2 9/115/190.003 MLA <4mm2 7/114/190.02 MLA <3mm2 4/111/190.03 Stent underexpansion is still important !!!

31. Sequential IVUS analysis of lumen and stent dimensions

35. Practical tips for treating ISR Prevent ISR using DES or properly expanded BMS! –much less diffuse ISR When treating ISR –Use preinflation/cutting balloon –Cover the whole stented segment with generous margins –IVUS guidance (mandatory for DES failure) –Optimally expand both stents with NC balloons

36. Conclusions DES can treat ISR as well (and probably better than) any other modality –including brachy and surgery!! Definitive trials will be published shortly Radiotherapy has a limited role in the future

37. TOO much radiation is bad for you

38. Even a little radiation can be bad for you! And who is that young man?

39. Don’t know but……

40. More pictures on SexyDrRobCrook.com.uk

41. Thank you The end

43. Ongoing studies

46. Final result does