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. 2023 May 18;2(4):100971. doi: 10.1016/j.jscai.2023.100971

Figure 3.

Figure 3

Stepwise, imaging-guided treatment of a calcified ISR lesion. In-stent restenosis of a first-generation drug-eluting stent (Taxus, Boston Scientific) in the mid LAD, implanted 18 years prior and confirmed patent several years afterward. Intrastent (type II) restenosis (A, inset with orthogonal view) was noted on angiography with multiple unsuccessful attempts made at dilatation (B, C) using noncompliant balloons (24-26 atm). Subsequent IVUS imaging (D, distal to proximal) reveals both calcified and noncalcified tissue within an appropriately sized stent, likely representing neoatherosclerosis. Despite successful rotational atherectomy (E: 1.5 mm burr, 160-170,000 rpm × 8 passes), non-compliant balloon dilation still revealed a focal waist (F). Complete expansion of a 2.5 × 12 mm Shockwave C2 IVL balloon was achieved after 80 pulses at 6 atm (G) and confirmed with IVUS. A 2.75 × 26 mm drug-eluting stent was implanted at 20 atm with excellent angiographic (G) and IVUS results. IVL, intravascular lithotripsy; IVUS, intravascular ultrasound; LAD, left anterior descending artery.