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. 2020 Sep 23;9(19):e016595. doi: 10.1161/JAHA.120.016595

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© 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

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A 43‐year‐old man undergoing dialysis received everolimus‐eluting stents in the right coronary artery (RCA) for stable angina. Coronary angiography results before (A) and after (B) stent implantation are presented. Optical coherence tomography (OCT) showed a high‐backscattering protruding mass with signal attenuation suggesting the calcified nodule (white asterisks) (A1 and A2). In addition, OCT demonstrated the protrusion of the calcified nodule (white arrow heads) after stent implantation (B1 and B2). Two months later, the patient underwent coronary angiography for symptoms of unstable angina pectoris. Coronary angiography (C) revealed in‐stent restenosis in the RCA. OCT (C1) showed a red thrombus (white arrow), while intravascular ultrasound (C1’) showed a thrombus (yellow arrow) and sheet calcification at the bottom (yellow arrow heads). OCT (C2) demonstrated attenuations (yellow asterisk) and intravascular ultrasound (C2’) demonstrated acoustic shadow (yellow cross) suggesting the presence of the calcified nodule. Low‐ (D) and high‐ (D’) power images of the tissue collected through directional coronary atherectomy revealed the calcified nodule with fibrin deposition (red arrow heads). PCI indicates percutaneous coronary intervention.