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Intravascular ultrasound-guided high-pressure balloon predilatation for optimal drug-eluting stent deployment in restenosis of a stent implanted 7 years earlier. Do we know the right technique for in-stent restenosis restenting?

Although off-label, drug-eluting stent (DES) implantation is a preferred intervention for in-bare metal stent restenosis (BMS ISR). Off-label DES implantation appears to be associated with a higher risk of stent thrombosis and lesion recurrence. Accordingly, routine BMS ISR restenting with DES is associated with more frequent subsequent thrombosis. Intravascular ultrasound (IVUS) studies point to stent underexpansion as the major mechanism of late DES failure. We report a case of a patient with BMS ISR in whom IVUS clarified initial BMS expansion; consequently, high-pressure predilatation with an angiographically oversized conventional balloon was applied prior to DES deployment; and finally, IVUS verified the stent expansion.