Coronary angioscopic imaging of in-stent restenosis after biolimus-eluting coronary stent implantation

A 69-year-old man underwent repeat percutaneous coronary intervention for in-stent restenosis in the obtuse marginal artery 8 months after biolimus-eluting stent (2.5 × 28 mm Nobori stent, Terumo, Tokyo, Japan) implantation. Coronary angiography showed focal stenosis in the distal part of the stent. Intravascular ultrasound revealed low echoic heterogeneous intimal tissue. Optical coherence tomography also revealed a heterogeneous finding classified as a layered pattern. Coronary angioscopy detected a white mass with a paste-like appearance at the stenosis extending around the in-stent restenosis as a thin membrane where stent strut could be seen transparently. A small part of the mass was swinging in the blood stream. Coronary angioscopic imaging was beneficial for the understanding of the suspected mechanism and feature of the in-stent restenosis after second-generation stent implantation, which was apparently different from neointimal hyperplasia after bare-metal stent implantation.