Despite numerous advances in coronary intervention techniques, in-stent restenosis (ISR) remains the Achilles heel of interventional cardiology. The incidence of ISR varies from 10-50% and depends on the absence or presence of several risk factors such as small vessel size, longer lesions, and diabetes. Drug-eluting stents (DES) have dramatically reduced the rates of restenosis and target vessel revascularization in a wide spectrum of patients with varying lesion morphologies. The interventionists must do a strategic evaluation of their patient before doing angioplasty to prevent ISR. Intracoronary imaging might help to understand the mechanism and to decide the management. In this article, we describe and compare the contemporary treatment modalities in patients who develop ISR. We also describe the role of imaging in the evaluation and characterization of in-stent restenosis. Various modalities of treatment like balloon angioplasty, cutting and scoring balloon, rotational atherectomy, excimer laser coronary angioplasty (ELCA), drug coated balloons, drug-eluting stents, brachytherapy, and the role of coronary artery bypass grafting (CABG) have been discussed.

Restenosis, hyperplasia, elastic recoil,vascular remodeling, neoatherosclerosi, neointimal