Peripheral ISR: DCB, IVL and debulking strategies – The cardiologist's point of view

This PVI 2025 session focuses on the evolving management of restenosis and the current evidence supporting different endovascular strategies across vascular territories.

The discussion highlights that drug-eluting technologies remain central in preventing restenosis, with drug-coated balloons showing safe and effective results in SFA in-stent restenosis, particularly in TOSAKA I and II lesions, with low target lesion revascularisation and encouraging 1-year outcomes. In more complex cases (TOSAKA III), adjunctive debulking strategies may be considered, although robust data remain limited.

Several illustrative cases further explore treatment strategies in challenging anatomies, including aorto-iliac in-stent restenosis due to stent underexpansion, successfully treated with intravascular lithotripsy followed by drug-coated balloon angioplasty, mirroring principles well established in coronary intervention. Additional cases address occlusive SFA in-stent restenosis treated with rotational atherectomy or laser debulking combined with drug-coated balloon angioplasty, with emphasis on restoring flow, minimising distal embolisation, and avoiding additional stent layers.

Overall, the session underscores that occlusive in-stent restenosis remains a complex challenge requiring tailored lesion preparation and device selection. It also highlights how recent technological advances have expanded the interventional toolbox, enabling operators to adapt strategies to lesion morphology, anatomical context, and procedural goals across peripheral revascularisation.