Case 218: Manual of PCI - Undilatable ISR

A patient with prior CABG and multiple prior PCIs, including PCI of a RCA CTO presented with dyspnea on exertion and was found to have significant in-stent restenosis of the RCA. He was referred for PCI. After wiring, equipment delivery was very challenging: a 2.5 mm balloon could not cross the mid RCA and a 2.0 mm Takeru balloon crossed partially but could not be delivered distally. After rewiring with a knuckled Sion black wire equipment delivery was easy. OPN balloon failed to expand the lesion and ruptured. Laser with contrast resulted in some improvement but there was residual stenosis. IVL was performed with nice but not perfect final result after DCB inflation and TIMI 3 flow.