- Patient initials or identifier number:
-Relevant clinical history and physical exam:
A 54-year-old male onchronic hemodialysis (HD), diagnosed as stable angina pectoris on old anteriormyocardial infarction, underwent percutaneous coronaryintervention (PCI) to diffuse moderatecalcified lesion in mid-right coronary artery (RCA) (A, B). At the initial PCI to RCA,Synergy biodegradable polymer everolims-eluting stent (3.5x38mm) was successfully placed withoutrotablator (C, D). His diabetic state was wellcontrolled, and dual antiplatelet therapy (DAPT) was continued.
-Relevant test results prior to catheterization:
However, 8 monthlater, the secondary PCI underwent for in-stent occlusion (ISO) (E). IVUS imageat the primary stenotic site (indicated by yellow arrow in each figure) showed almostcircular superficial high-intensity layer with acoustic shadowing inside stent mimicking in-stentcalcification (ISC) (F, struts of expanded stent were indicated by yellowbroken-lined arrows). However, ISC in ISO was fully dilated by 3.5mm-sized non-compliantballoon and drug-coated balloon without indentation (G, H).
- Relevant catheterization findings:
One-year later,however, severe in-stent restenosis (ISR) at the primary stenotic site was recurred(I) with recurrent superficial high-intensity layer (J). Opticalcoherence tomography (OCT) image showed layered neo-intimal pattern as high-backscattering growing mass with signalattenuation (seen in 4 to 9 o’clock) representing thick neo-intima growth inside Synergy stent, without characteristicsharp bordered low-intensity presentation of calcification (K).