Management of Ostial Left Anterior Descending Intrastent Restenosis: The Value of IVUS in Diagnosing and Guiding PCI

Coronary ostial lesions remain among the most challenging lesions encountered in interventional cardiology because of their complex anatomy, frequent angiographic ambiguity, and high risk of procedural complications. Precise differentiation between true ostial disease, proximal vessel involvement, and left main coronary artery extension is crucial for optimal therapeutic planning. Intravascular imaging has emerged as an essential tool in this setting by providing accurate lesion characterization and guidance for intervention. We report the case of a 72-year-old man with multiple cardiovascular comorbidities, including diabetes mellitus, hypertension, chronic kidney disease requiring hemodialysis, and a history of multivessel percutaneous coronary intervention. He presented with recurrent deterioration of left ventricular systolic function and elevated NT-proBNP levels. Coronary angiography demonstrated a severe stenosis involving the ostium of the left anterior descending artery; however, angiographic assessment alone could not determine whether the lesion represented true ostial in-stent restenosis or extension into the distal left main coronary artery. Intravascular ultrasound was therefore performed and confirmed isolated ostial left anterior descending artery in-stent restenosis due predominantly to neointimal hyperplasia. The lesion was successfully treated using excimer laser coronary atherectomy followed by high-pressure balloon dilatation and paclitaxel-coated balloon angioplasty under intravascular ultrasound guidance. This case highlights the critical role of intravascular imaging in the diagnosis and treatment of complex ostial coronary lesions and illustrates a contemporary strategy for managing ostial in-stent restenosis while avoiding additional stent implantation.