Bare metal stent implantation for in-stent restenosis with a drug-eluting stent

Following the positioning of a bare metal stent (BMS) implant, a yellow plaque is healed with a reduction of the color grade and thrombogenicity, i.e. vulnerability by angioscopy in the chronic phase ("plaque sealing" of BMS; the "whitening effect" of BMS). However, we have reported that thrombus and yellow plaque increases at the drug-eluting stent (DES) site. A 71-year-old man underwent percutaneous coronary intervention using two DESs for a severe stenotic lesion in his right coronary artery. Follow-up coronary angiography (CAG) showed in-stent restenosis (ISR) at the stent-overlap site. We performed traditional balloon angioplasty, but follow-up CAG showed ISR again at the same position as the first restenosis. In angioscopic findings, the normal vessel wall was white, but the site of DES implantation was yellow and a yellow, soft, swelling neointimal proliferation-like vulnerable plaque was observed at the restenotic site. In expectation of the "whitening effect" of BMS, we implanted a new BMS. As anticipated, follow-up CAG showed no restenosis. Moreover, the angioscopic findings indicated a clean, white, neointimal proliferation-like stable plaque at the BMS implant site in the yellow vulnerable area of DES. The "BMS in DES" therapy should be considered one of the strategies for ISR of DES.