Abstract
Although intravascular lithotripsy (IVL) has been introduced as an effective method for treating severely calcified native coronary artery lesions, its use in in-stent restenosis (ISR) lesions is still off-label. We report a 71-year-old man with a previous percutaneous coronary intervention (PCI) to the left circumflex coronary artery (LCX) who was readmitted for ST-segment elevation myocardial infarction. Coronary angiography showed a total occlusion at the middle portion of the first diagonal branch, a significant stenosis in the proximal left anterior descending coronary artery, and a diffuse significant stenosis including ISR of the previously stented segment in the proximal to mid LCX. The occluded culprit lesion of the diagonal branch was successfully reperfused. Optical frequency domain imaging during staged PCI for the LCX lesion revealed severe calcified in-stent neoatherosclerosis. Multiple dilatations with balloons all failed. Thus, IVL was successfully used to modify the underlying calcified neointima. Two drug-coated balloons were then utilized to cover the whole stenotic segment with optimal lumen gain. One year later, the patient remains event-free. LEARNING OBJECTIVES: Although the use of intravascular lithotripsy (IVL) for in-stent restenosis (ISR) remains an off-label indication, this case indicates that the combination of IVL and drug-coated balloon angioplasty may represent an effective treatment strategy for calcified ISR.