Concise evidence‑referenced summary — coronary restenosis after POBA (78‑yr‑old woman on recent DAPT)

Below is a focused, actionable plan covering mechanisms, immediate invasive options, procedural considerations, and antiplatelet guidance with key evidence/guideline pointers.

Mechanisms (brief)

Late restenosis after POBA is driven mainly by neointimal hyperplasia — smooth muscle cell proliferation and extracellular matrix deposition following endothelial injury. Early contributors include elastic recoil and thrombus; neoatherosclerosis can appear months–years later.

Management options for focal coronary restenosis after POBA

Drug‑eluting stent (DES) — preferred when definitive scaffolding is needed (reduces restenosis vs BMS/POBA). Consider if recoil, flow‑limiting dissection, or recurrent restenosis after balloon strategies.
Drug‑coated balloon (DCB) — reasonable for focal restenosis when avoiding extra metal is desirable (preserve future options). Requires excellent lesion preparation and low residual stenosis; less robust coronary data than for peripheral disease but used clinically and in selected studies.
Repeat POBA — limited durability; may be used palliatively or when other options unsuitable.

Procedural/practical points

Lesion preparation is critical: use adequate pre‑dilation (and debulking if needed) to obtain residual stenosis <30% and minimize dissections that compromise drug uptake.
Be prepared for provisional stenting if flow‑limiting dissection or significant recoil occurs — this changes antiplatelet planning.
When using DCB, avoid leaving major dissections untreated; if stent required, implanting a DES is preferred over BMS in most cases to lower re‑restenosis.

Antiplatelet strategy (patient on recent DAPT after coronary stent)

Do not stop DAPT routinely before coronary re‑intervention — continuing DAPT through the procedure is generally safest to avoid stent thrombosis.
If provisional stenting is needed, continue/extend DAPT according to coronary stent guidelines and time since the index PCI; coordinate with the operator who placed the prior cardiac stent.
Balancing bleeding risk: if bleeding risk is very high, involve multidisciplinary team (interventional cardiology, hematology) to individualize changes; consider strategies like minimizing additional stent implantation and using shortest evidence‑based DAPT durations post‑stent.

Follow‑up and secondary prevention

Optimize secondary prevention: high‑intensity statin (unless contraindicated), blood pressure control, glycemic control (diabetes), smoking cessation, and cardiac rehab as appropriate.
Schedule clinical follow‑up and noninvasive ischemia testing or repeat angiography if recurrent symptoms. Tailor surveillance to symptom severity and baseline ischemic risk.

Key evidence & guideline references (concise)

Drug‑eluting stents vs balloon strategies: Numerous RCTs/meta‑analyses show DES superiority over balloon or BMS for reducing restenosis and repeat revascularization in coronary disease (see ESC and ACC/AHA PCI guidance summaries).
Drug‑coated balloons: Evidence supports DCB use in selected in‑stent restenosis and focal lesions; smaller/heterogeneous coronary series compared with larger peripheral literature — use selectively.
Antiplatelet guidance: Recent PCI guidelines (ESC, ACC/AHA) recommend continuation of required DAPT after recent coronary stent when feasible for subsequent coronary procedures; any modification should weigh ischemic vs bleeding risks and be individualized.

If you’d like, I can now: (A) produce a one‑page printable checklist for the operator and cardiology team; (B) give specific recommended DAPT durations depending on DES type and time since the prior PCI; or (C) list 3 key trials/reviews supporting the above. Which do you want?

Learning: why does restenosis occur after poba and how to treat it?