CONGRESS ABSTRACT

Introduction In-stent restenosis (ISR) in calcified lesions poses a significant challenge in percutaneous coronary intervention (PCI). Adequate lesion preparation is crucial to optimize treatment efficacy, particularly when considering Drug-Coated Balloon (DCB) angioplasty. Here, we describe a case in which lesion preparation with Cutting Balloon (CB) facilitated calcium modification, enhancing the effectiveness of DCB therapy and obviating the need for repeat stenting.   Case Presentation An 81-year-old female with multiple cardiovascular risk factors and previous PCI on proximal left anterior descending artery (LAD) presented to our center with unstable angina. Emergent coronary angiography showed severe ISR in the proximal LAD. Intravascular Ultrasound (IVUS) demonstrated a fibrotic in-stent neointimal proliferation with a deep and thin circumferential layer of calcium (minimal lumen area (MLA): 2.51 mm²) (Figure 1). Lesion preparation was performed with downsized high-pressure CB inflation (3.5 x 10mm Wolverine, Boston Scientific Corporation, Marlborough, MA) and 1:1 sized Non-Compliant Balloon inflation (4.0 x 15mm). This strategy was effective in plaque modification. IVUS showed significant calcium fractures and fibrotic plaque compression, suggesting effective mechanical remodelling of the lesion (Figure 2). Subsequently, 1:1 sized DCB inflation was performed (4.0 × 15 mm Agent, Boston Scientific Corporation, Marlborough, MA), with calcium fractures enhancing drug absorption and efficacy. Final IVUS assessment (Figure 3) demonstrated a substantial luminal gain, with MLA increasing from 2.51 mm² to 8.12 mm², thereby avoiding the need for additional stent placement.   Conclusion High-pressure downsized CB inflation effectively modified deep calcified in-stent stenotic plaque, improving vessel compliance and creating favorable conditions for subsequent DCB therapy. This approach enhanced drug uptake and efficacy, maximizing the pharmacological benefit of DCB treatment. The substantial luminal gain achieved obviated the need for further stent implantation, highlighting the role of CB in complex ISR cases.