Original Studies Choice of Stent and Outcomes After Treatment of Drug-Eluting Stent Restenosis in Highly Complex Lesions Xavier Freixa, MD, Ali S. Almasood, MD, Sohail Q. Khan, MD, Karen Mackie, RN, Mark Osten, MD, Douglas Ing, MD, Christopher B. Overgaard, MD, Eric M. Horlick, MD, Peter H. Seidelin, MD, FSCAI, and Vladimı´r Dz ˇ avı´k, * MD, FSCAI Objectives: Our aim was to compare the outcomes of a same versus different drug- eluting stent (DES) implantation strategy for the treatment of DES instent restenosis (ISR). Background: The absence of clear data renders the treatment of DES ISR one of the most challenging situations in interventional cardiology. Methods: We identified all cases of DES ISR treated with a second DES between January 2004 and January 2009. The lesions were divided into those treated with the same DES as the initial one that restenosed and those treated with a different DES. The main end-point was repeat tar- get lesion revascularization (TLR). Results: We included 116 patients with a total of 132 lesions. The patient population was highly complex: 55.5% with diabetes, 56% with type-C lesions, 15.9% with lesions previously stented with BMS and 18.2% with fluoro- scopic evidence of stent fracture. A same and different stent strategy was conducted in 41 lesions (31%) and 91 lesions (69%), respectively. Overall TLR was 31.1% and occurred in 46.3% of patients treated with the same stent and 24.4% of those with a different stent (P 5 0.012). Multivariable analysis found same stent strategy (OR 2.84, 95%CI 1.23–6.57;P 5 0.014) and occurrence of stent fracture (OR 4.03, 95%CI 1.33–12.01;P 5 0.012) to be the only independent predictors of TLR after a median follow-up of 20.4 [12.1–30.2] months. Conclusions: In highly complex lesions, DES implantation for DES ISR is linked to a high need of future revascularization. An associ- ation between implanting a DES type other than the original and lower rate of TLR is suggested. V C 2012 Wiley Periodicals, Inc. Key words: drug-eluting stents; in-stent restenosis; repeated revascularization; same stent; different stent INTRODUCTION The use of drug-eluting stents (DES) has resulted in a marked reduction in the incidence of in-stent resteno- sis (ISR) after percutaneous coronary intervention (PCI) [1,2]. However, when it does occur, ISR of DES represents one of the most challenging situations in interventional cardiology. Because there are few data and therefore no formal recommendations available, several different PCI strategies have been developed. The better outcome associated with the use of DES in cases of bare-metal stent (BMS) ISR [3–5] is probably the main reason why the repeat deployment of a DES has become the most widely utilized strategy for DES ISR treatment. The deployment of a second DES to treat a DES ISR (sandwich-technique) seems to be a Peter Munk Cardiac Centre, University Health Network, Inter- ventional Cardiology Program, Division of Cardiology, Toronto, Ontario, Canada Conflict of interest: Dr. Dz ˇavı ´k has received research funding from Abbott Vascular and unrestricted educational funds from Cordis, Johnson & Johnson. *Correspondence to: Dr. Vladimı ´r Dz ˇavı ´k, MD, FSCAI, Interven- tional Cardiology Program, Peter Munk Cardiac Centre, University Health Network, 6-246 EN Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4. E-mail: vlad.dzavik@uhn.on.ca Received 26 May 2011; Revision accepted 10 December 2011 DOI 10.1002/ccd.24291 Published online in Wiley Online Library (wiley onlinelibrary.com) V C 2012 Wiley Periodicals, Inc. Catheterization and Cardiovascular Interventions 00:000–000 (2012)