So as many of you have guessed correctly this is a case of ISR 2/2 to Late acquired stent malapposition (LASM). This diagnosis wouldn't have been possible unless you #Imagefirst. But is that that simple. Let's see...
https://twitter.com/AntoniousAttall/status/1334533340733575174
1. We used a 4.0 mm stent proximally in the initial case and then "flared" the ostium with a 4.5 mm NC
2. Here is the full IVUS run. The stent is appropriately sized to the refence segment. We didn't aggressively post dilated the positively remodeled and clot rich proximal/ostial stent but ended up with a big lumen...
3. The pt came back a year later with similar anginal symptoms. We obviously were concerned about new disease elsewhere but his other stent were patent but then we saw this...
4. Here is the IVUS run. Severe ISR with LASM compared to initial IVUS. But what's going on at the ostium?
5. My working diagnosis at this point that we have LASM, but I am concerned that this angry inflammatory response may have been brought on by fracture of the stent at the os against a heavily calcified portion.
6. 
7. So we began dilating with 4.0 NC which was useless, followed by 4.0 Wolverine with some improvement but still with recoil. We ended up restenting with 4.5 and high pressure dilating with 5.0 NC...
@mmamas1973 @drandrewsharp @poojaotherwise @toreyj01 @aspergian1 @lorenzo2509 @ShariqShamimMD @GreggWStone @DocSavageTJU @hectortamezmd @BaoGTran @HadyLichaaMD @ziadalinyc @Almanfi_Cardio @DrAmirKaki @rajivxgulati @KhandelwalMD @Babar_Basir @DrJayMohan @JayMathewsMD
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