A 48-year-old female had undergone PCI with stents to LAD in January 2021. She presented with unstable angina in January 2023 to another centre where angiography showed two stents in LAD with significant overlap and long segment ISR with 90% stenosis. LAD stent was predilated with 2.5mm NC and treated with 3mm x 35 mm sirolimus-coated balloon(MagicTouch) in mid lad. A 3mm x 12 mm everolimus-eluting stent was deployed in ostio-proximal LAD with distal segment overlap with the older stent. 
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The patient was compliant with medication and was physically active for the next 5 months. Patient presented to us in July 2023 with exertional angina in the preceding month and rest angina for the last 3 days. ECG showed no significant ST-T changes. Echocardiography showed no regional wall motion abnormalities with LV ejection fraction of 60%. Troponin was not elevated. Considering the typical history of angina and previous history of stent failure, she underwent coronary angiography. 

Angiography showed new ISR in LAD at the distal end of the recently deployed ostio-proximal stent with significant stenosis. The stent in the LCX was patent, and RCA had a mild plaque. A decision was made to revascularise the LAD ISR under IVUS guidance.
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JL 3.5 (6Fr) guide was used transfemorally. Lesion was dilated with 2mm semi-compliant balloon. IVUS run confirmed that the wire was entirely inside stent lumen. Distal stent segment had a vessel diameter of 2.6 mm with well-apposed stent and stent area of 5 mm². The middle segment and ostio-proximal stent segment had underexpanded and malapposed stent (stent area of 4.3 mm² and 4.6 mm²respectively). Stent underexpansion, significant overlap and multiple stents appeared to have contributed to repeated stent failure. Lack of imaging-guided optimization in the previous procedure had led to DCB failure. Proximal and mid stent segment was dilated with 2.5mm Wolverine cutting balloon. The mid stent segment was dilated with 3.5 mm NC balloon. Dilatation of NC balloon at the ostio-proximal segment caused slipping of the balloon. It was dilated with 3mm Wolverine cutting balloon after which further dilatation with 4mm x 8 mm non-compliant balloon was possible. Repeat IVUS run showed well expanded middle stent segment with stent area of 7.2 mm² and mean stent diameter of 3mm. The ostio-proximal stent segment had stent area of 9mm² with mean stent diameter of 3.4mm. The total stented segment was 49 mm in length as measured by IVUS. Mid to distal segment was treated with 2.75mm x 20 mm sirolimus-coated balloon (MagicTouch). Ostium to middle stent segment was treated with 3.5mm x 30 mm sirolimus-coated balloon (MagicTouch). Final angiogram showed good result with no complications.
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Correction of the contributing factors like stent under-expansion is essential for the success of drug-coated balloon. Intravascular imaging helps identify the contributing factors and optimize percutaneous coronary intervention in patients with repeated stent failure.