• New App to Help Treat ISR Using Intravascular Imaging Introduced at CRT 2021

    The Waksman Classification of In-Stent Restenosis now has an app.

    Hayder Hashim, MD, of MedStar Washington Hospital Center, Washington, D.C., introduced the app during a presentation Saturday as part of CRT 2021 Virtual’s final week.

    The app features a guide to imaging in-stent restenosis (ISR) with optimal coherence tomography (OCT) based on the classification.

    The classification, named after CRT 2021 Virtual Course Chairman Ron Waksman, MD, of MedStar Washington Hospital Center was first published in July 2019 in Circulation: Cardiovascular Interventions. The treatment algorithm calls for intravascular imaging (intravascular ultrasound [IVUS] or OCT) to be the first step in assessing ISR lesions, which are then classified into one of five types: Type I (mechanical: underexpansion or stent fracture), Type II (biologic: neointimal hyperplasia or neoatherosclerosis with or without calcification), Type III (mixed, mechanical or biologic), Type IV (chronic total occlusion [CTO]) or Type V (more than two layers of drug-eluting stent [DES] ISR).

    Each classification level has several treatment options. For example, treatment options for an underexpanded stent include high-pressure balloon, excimer laser coronary atherectomy, intravascular lithotripsy, or rotational or orbital atherectomy.

    Hashim said that previous classification systems were based on angiography and bare metal stents (BMS).

    “Our lab is an intravascular-heavy lab,” he said. “We really believe that it’s a cornerstone in any case of DES-ISR or BMS-ISR to understand exactly using intravascular imaging.”

    The app shows these classifications, subcategories and treatment options.

    Hashim showed an example of neointimal hyperplasia, which displays OCT images and gives an overview. Interventional cardiologists who download the app can submit their own images (must comply with the Health Insurance Portability and Accountability Act), which might be added to the app’s available images.

    “This is almost like a mini-peer-review publication to this app,” he said. “You have run through a good ISR case with OCT. You think it’s going to be beneficial. You have a good finding. You can submit your picture. It will come to us, we’ll review it, and we’ll push it to the app. And, obviously, this will always have reference to you, to your work and to your institution.”

    The app is available on both the Apple App Store and Google Play Store.

    “That’s amazing, what the world’s coming to,” said James P. Zidar, MD, moderator of the CRT session during which the Waksman Classification and app were presented.

    Gary S. Mintz, MD, of the Cardiovascular Research Foundation, further discussed IVUS-guided percutaneous coronary intervention. During his presentation, Mintz affirmed the importance of imaging complex lesions to achieve the best stent placement possible and strive to avoid ISR in the first place. He pointed out one recent study that shows a 5-year mortality rate for patients with treated ISR of 30.2%.

    “Not trivial,” Mintz said. “Restenosis is not a benign event.”

    He added that a minority of fellows are trained to perform either IVUS or OCT – something that needs to be improved.

    Kevin Croce, MD, PhD, of Brigham and Women’s Hospital, Boston, discussed laser atherectomy, and Goran Stankovic, MD, PhD, of University Clinical Center of Serbia, presented techniques for treating complex bifurcation lesions.

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