An effective treatment for repeated coronary in-stent restenosis using rotational atherectomy after aggressive wire penetration through the calcified nodule: a case report.

Background: Lesions with calcified nodules (CNs) have a significantly higher rate of restenosis. There is no definitive and effective medication or procedural technique to suppress the progression of CNs. Case summary: A 71-year-old was referred to our hospital because of typical effort angina pectoris. Diagnostic coronary angiography identified significant severe stenosis in the middle segment of right coronary artery (RCA). In the primary percutaneous coronary intervention (PCI), intravascular ultrasound visualized the eccentric protruding high echoic structure with irregular surface indicating CNs. Percutaneous coronary intervention was successfully performed with rotational atherectomy (RA). However, one year after the PCI, effort angina was recurrent. The patient experienced recurrent restenosis three times, even after repeated PCI using RA and treatment with drug coating balloon. In the fourth PCI, we tried guide wire penetration through the CNs before RA to reduce the more amount of CNs tissue; finally, good patency was achieved. At last, follow-up angiography after final PCI showed no in-stent restenosis. Discussion: We report a case of a patient who required repeated revascularization to a severe stenotic lesion with CNs in the middle segment of the RCA. Rotational atherectomy after wire penetration into the CNs was effective to avoid a malignant cycle of restenosis.