Management of recurrent in-stent restenosis: onion skin full metal jacket?

Treatment of patients with in-stent restenosis (ISR) remains a technical challenge and continues to represent a major clinical problem1. Although bare metal stents (BMS) are still widely used they suffer from a relatively high restenosis rate, especially in complex clinical and anatomic scenarios1,2. Drug-eluting stents (DES) have drastically reduced the appearance of severe neointimal proliferation and the clinical need for repeat revascularisation. However, some patients treated with DES still develop ISR1,2. Timing, morphological patterns, underlying substrate and response to treatment differ slightly in patients with DES-ISR and those with BMS-ISR1. Indeed, DES-ISR may present relatively late after the initial procedure, ...