Combined use of intravascular lithotripsy and brachytherapy: A new approach for the treatment of recurrent coronary in-stent restenosis.

Treatment of coronary in-stent restenosis (ISR) is challenging and often requires combination of multiple treatment modalities. Coronary intravascular lithotripsy (IVL) has been successfully used for treating stent under-expansion, but is not currently commercially available in the United States. We present three recurrent coronary ISR cases in which multiple treatment modalities (high-pressure balloon inflation, plaque modification balloons, and laser with contrast injection) failed. These patients were treated with a combination of IVL (peripheral IVL catheter used off-label in the coronary arteries) and brachytherapy. Due to the high IVL balloon profile, delivery via femoral or radial access was challenging, requiring 7-8 French guide catheters. IVL was performed delivering 4-8 treatments of 20 pulses each with a favorable final angiographic and intravascular ultrasound result. All patients were angina free 1 month after the procedure.