WHAT IS THE BEST TREATMENT CHOICE FOR LIMUS - ISR?

To be fair, we do not see much Limus - ISR anymore. I remember when we were just doing Plain Old Balloon Angioplasty ( POBA ) back in the 80s, every 2nd or 3rd patient will return with chest pains. When we started using bare metal stents from the 90s, we were seeing one in four to five, come back with chest pains. Now with the DES, we are seeing maybe one a year. The second generation DES is even better, one comes back, once in a while, like 2-3 years. Obviously, the cobalt chromium thin struts limus-coated stents are good.
Anyway, should they restenose, what are our options. This happen to one of my patient, DES implanted in 2005 in the LAD. He had the first generation Cypher stent. The re-stenosis was in the middle of the stent, fairly discreet. I decided that the best option was to use a Drug Eluting Balloon to treat the lesion. I used a Pantelux DEB ( Paclitexal coated ), and in-dwell for about 60secs.. Simple straight forward procedure, took about 45 mins and patient was discharged the next morning. Cost about RM 17K.
I am happy to note that there is some data supporting what I did. In the just completed TCT ( Transcatheter Therapeutics ) Annual Scientific meeting ( probably the largest Interventional meeting in the world today ), the ISAR group from Munich Germany, presented their study comparing the use of a DEB ( Paclitexal coated ) against a Taxus Stent ( Paclitexal Coated DES ), and POBA. There were 402 patients enrolled, divided into the 3 arms. Follow-up was 12 months ( clinical FU ). At the end of 1 year, they found that the POBA arm did the worse. The re-re-stenosis was high and significantly more than the other 2 arms. The Taxus stent did the best, but was not significantly better than the DEB.
Of course, the issue now could be, if they have used a limus-DES in one arm? I suppose the ISAR investigators were mindful of the fact that it was a limus-DES re-stenosis, so they used a paclitexal alternative. I suppose, theoretically, if one were to use a second generation limus-DES, the results should be better.
I suppose the lesson that I learn is that you do not need more metal, when there is limus-ISR. DEB works well, probably as well as a DES.
Well, I have to follow up my patient and see how well he does.