Case was 70's female, and she had a history of paroxysmal atrial fibrillation, chronic kidney disease with hemodyalysis. She was diagnosed with angina pectoris and PCI was performed for RCA ostium with drug-eluting stent. Subsequently, in-stent restenosis was occurred repeatedly. Finally Biolimus-A9 Coated Stent was deployed within the stent, and follow up CAG with coronary angioscopy was performed. ECG showed sinus rhythm with inverted T wave of V1-4, and UCG showed normal LV function.

At the first procedure, underexpanded stent was deployed without debulking for eccentric calcified plaque of RCA ostium lesion. 1 year and 2 months after the initial procedure, in-stent restenosis due to underexpanded stent was occurred. PCI was performed with drug-coated balloon and another 8 months later, re-restenosis with neointima hyperplasia was occurred. 

We used 7Fr JR3.5SH guiding and SION blue ES wire. Wire was easily crossed, and IVUS showed in-stent restenosis with neointimal hyperplasia and underexpanded stent. Long inflation technique using cutting balloon was performed, and Biolimus-A9 coated stent was deployed for in-stent lesion. Post dilation using NC balloon was performed, and procedure was completed. 4 months and 1year and 9 months after the procedure, follow up CAG with coronary angioscopy was performed.

1 year and 2 months after the initial procedure using underexpanded stent for eccentric calcified plaque placed at RCA ostium, in-stent restenosis was occurred. PCI was performed with drug-coated balloon and another 8 months later, re-restenosis was occurred. PCI was performed again with Biolimus-A9 coated stent deployed for in-stent lesion. 4 months, and 1 year and 9 months after the stent implantation, CAG was performed with evaluating coronary angioscopy. At the 4 months later, there was no restenosis and we confirmed beginning of neointima coverage for stent strut. At the 1 year and 9 months later, there was also no restenosis, and we confirmed enough and optimal neointimal coverage as vessel healing after stent implantation. Biolimus-A9 coated stent has early drug release system and polymer-free characteristics. The characteristics of the stent may have contributed to get the early smooth and optimal neointimal coverage, and the prevention of malignant cycle of RCA ostium in-stent restenosis.

Biolimus-A9 coated stent was deployed for RCA in-stent restenosis lesion, and there was no restenosis at least 2 years after the procedure. The stent may have a possibility of improve the status of in-stent restenosis case with underexpanded stent.